tag:blogger.com,1999:blog-50368913621249717032024-03-14T01:52:50.108-04:00Ortho On The Web NewsletterEach posts serves as a separate edition of the newsletter for my website Ortho On The Web. This newsletter is dedicated to patient and physician education regarding orthopedic matters as they relate to my orthopedic surgery practice. This is an opportunity to display some of the complex and interesting seen in my practice. I add to the newsletter and send out notices periodically. Check out the website @ OrthoOnTheWeb.com.
James T Mazzara, MDUnknownnoreply@blogger.comBlogger115125tag:blogger.com,1999:blog-5036891362124971703.post-3798705323414944122012-05-23T10:51:00.000-04:002012-05-23T10:51:11.873-04:00Frozen Shoulder<br />
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">I see many patients daily with a certain degree of stiffness of the joint contributing to their shoulder pain. Sometimes the loss of motion is o</span><span style="font-family: 'Trebuchet MS', sans-serif;">bvious and dramatic and sometimes it is very subtle and only noted when we compare the other shoulder. Below is some educational information from the AAOS that I found very helpful for patients.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Frozen shoulder occurs in about 2% of the general population. It most commonly affects people between the ages of 40 and 60, and occurs in women more often than men.</span></div>
<div class="header1" style="background-color: white; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 371px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Anatomy" style="color: blue;"></a>Anatomy</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.</span></div>
<div class="figbox" style="background-color: white; border: 1px solid rgb(0, 51, 153); clear: none; float: none; margin: 20px 10px 10px; padding: 5px; text-align: center; width: 300px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00071F01.jpg" style="clear: both;" /></span><div style="margin: 5px; text-align: left;">
<span style="font-family: 'Trebuchet MS', sans-serif;">The shoulder capsule surrounds the shoulder joint and rotator cuff tendons.</span></div>
<div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Reproduced and modified from The Body Almanac. (c) American Academy of Orthopaedic Surgeons, 2003.</span></div>
</div>
<div class="header1" style="background-color: white; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 371px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Description" style="color: blue;"></a>Description</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">The hallmark sign of this condition is being unable to move your shoulder - either on your own or with the help of someone else. It develops in three stages:</span></div>
<div style="background-color: white; margin-left: 20px; margin-right: 20px;">
<h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Freezing</span></h4>
<div style="padding-top: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">In the"freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.</span></div>
</div>
<div style="background-color: white; margin-left: 20px; margin-right: 20px;">
<h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Frozen</span></h4>
<div style="padding-top: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.</span></div>
</div>
<div style="background-color: white; margin-left: 20px; margin-right: 20px;">
<h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Thawing</span></h4>
<div style="padding-top: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.</span></div>
<div class="figbox" style="border: 1px solid rgb(0, 51, 153); clear: none; float: none; margin: 20px 10px 10px; padding: 5px; text-align: center; width: 500px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00071F02.jpg" style="clear: both;" /></span><div style="margin: 5px; text-align: left;">
<span style="font-family: 'Trebuchet MS', sans-serif;">In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.</span></div>
</div>
</div>
<div class="header1" style="background-color: white; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 371px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Cause" style="color: blue;"></a>Cause</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Diabetes.</strong> Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Other diseases.</strong> Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Immobilization.</strong> Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.</span></div>
<div class="header1" style="background-color: white; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 371px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Symptoms" style="color: blue;"></a>Symptoms</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.</span></div>
<div class="header1" style="background-color: white; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 371px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Doctor Examination" style="color: blue;"></a>Doctor Examination</span></div>
<div style="background-color: white; margin-left: 20px; margin-right: 20px;">
<h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Physical Examination</span></h4>
<div class="figbox" style="border: 1px solid rgb(0, 51, 153); clear: none; float: right; margin: 20px 10px 10px; padding: 5px; text-align: center; width: 150px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00071F03.jpg" style="clear: both;" /></span><div style="margin: 5px; text-align: left;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Your doctor will test the range of motion in your shoulder.</span></div>
<div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.</span></div>
</div>
<div style="padding-top: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">After discussing your symptoms and medical history, your doctor will examine your shoulder. Your doctor will move your shoulder carefully in all directions to see if movement is limited and if pain occurs with the motion. The range of motion when someone else moves your shoulder is called "passive range of motion." Your doctor will compare this to the range of motion you display when you move your shoulder on your own ("active range of motion"). People with frozen shoulder have limited range of motion both actively and passively.</span></div>
</div>
<div style="background-color: white; margin-left: 20px; margin-right: 20px;">
<h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Imaging Tests</span></h4>
<div style="padding-top: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Other tests that may help your doctor rule out other causes of stiffness and pain include:</span></div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>X-rays.</strong> Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in your shoulder, such as arthritis.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Magnetic resonance imaging (MRI) and ultrasound.</strong> These studies can create better images of problems with soft tissues, such as a torn rotator cuff.</span></div>
<div class="header1" style="background-color: white; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 371px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Treatment" style="color: blue;"></a>Treatment</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Frozen shoulder generally gets better over time, although it may take up to 3 years.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">The focus of treatment is to control pain and restore motion and strength through physical therapy.</span></div>
<div style="background-color: white; margin-left: 20px; margin-right: 20px;">
<h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Nonsurgical Treatment</span></h4>
<div style="padding-top: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">More than 90% of patients improve with relatively simple treatments to control pain and restore motion.</span></div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Non-steroidal anti-inflammatory medicines.</strong> Drugs like aspirin and ibuprofen reduce pain and swelling.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Steroid injections.</strong> Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Physical therapy.</strong> Specific exercises will help restore motion. These may be under the supervision of a physical therapist or via a home program. Therapy includes stretching or range of motion exercises for the shoulder. Sometimes heat is used to help loosen the shoulder up before the stretching exercises.. Below are examples of some of the exercises that might be recommended.</span><br />
<ul>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong>External rotation — passive stretch.</strong> Stand in a doorway and bend your affected arm 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30 seconds. Relax and repeat.</span></li>
<div class="figbox" style="border: 1px solid rgb(0, 51, 153); clear: none; float: none; margin: 20px 10px 10px; padding: 5px; text-align: center; width: 250px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00071F04.jpg" style="clear: both;" /></span><div style="margin: 5px; text-align: left;">
<span style="font-family: 'Trebuchet MS', sans-serif;">External Rotation - Passive Stretch</span></div>
<div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.</span></div>
</div>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Forward flexion — supine position.</strong> Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.</span></li>
<div class="figbox" style="border: 1px solid rgb(0, 51, 153); clear: none; float: none; margin: 20px 10px 10px; padding: 5px; text-align: center; width: 250px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00071F05.jpg" style="clear: both;" /></span><div style="margin: 5px; text-align: left;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Forward Flexion - Supine Position</span></div>
<div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.</span></div>
</div>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Crossover arm stretch.</strong> Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.</span></li>
<div class="figbox" style="border: 1px solid rgb(0, 51, 153); clear: none; float: none; margin: 20px 10px 10px; padding: 5px; text-align: center; width: 150px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00071F06.jpg" style="clear: both;" /></span><div style="margin: 5px; text-align: left;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Crossover Arm Stretch</span></div>
<div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.</span></div>
</div>
</ul>
</div>
<div style="background-color: white; margin-left: 20px; margin-right: 20px;">
<h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Surgical Treatment</span></h4>
<div style="padding-top: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">If your symptoms are not relieved by therapy and anti-inflammatory medicines, you and your doctor may discuss surgery. It is important to talk with your doctor about your potential for recovery continuing with simple treatments, and the risks involved with surgery.</span></div>
<span style="font-family: 'Trebuchet MS', sans-serif;">The goal of surgery for frozen shoulder is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Manipulation under anesthesia.</strong> During this procedure, you are put to sleep. Your doctor will force your shoulder to move which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases range of motion.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Shoulder arthroscopy.</strong> In this procedure, your doctor will cut through tight portions of the joint capsule. This is done using pencil-sized instruments inserted through small incisions around your shoulder.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">In many cases, manipulation and arthroscopy are used in combination to obtain maximum results. Most patients have very good outcomes with these procedures.</span><br />
<div class="figbox" style="border: 1px solid rgb(0, 51, 153); clear: none; float: none; margin: 20px 10px 10px; padding: 5px; text-align: center; width: 350px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00071F07.jpg" style="clear: both;" /></span><div style="margin: 5px; text-align: left;">
<span style="font-family: 'Trebuchet MS', sans-serif;">These photos taken through an arthroscope show a normal shoulder joint lining <strong>(left)</strong> and an inflamed joint lining damaged by frozen shoulder.</span></div>
<div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;">
</div>
</div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Recovery.</strong> After surgery, physical therapy is necessary to maintain the motion that was achieved with surgery. Recovery times vary, from 6 weeks to three months. Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Long-term outcomes after surgery are generally good, with most patients having reduced or no pain and greatly improved range of motion. In some cases, however, even after several years, the motion does not return completely and a small amount of stiffness remains.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span><br />
<span style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;"><a href="http://orthoinfo.aaos.org/topic.cfm?topic=A00071" target="_blank">From the AAOS</a></span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span><br />
<br /></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-59931253592846678462012-05-23T08:56:00.002-04:002012-05-23T08:56:14.929-04:00Osteonecrosis of the Knee<br />
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">A relatively common cause of knee pain in older women occurs when a segment of bone loses its blood supply and begins to die. This condition is called osteonecrosis, which literally means "bone death." More than 3 times as many women as men are affected; most are over the age of 60 years.</span></div>
<div class="header1" style="background-color: white; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Cause" style="color: blue;"></a>Cause</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">In the knee, the knobby portion of the thighbone on the inside of the knee (the medial femoral condyle) is most often affected. However, osteonecrosis of the knee may also occur on the outside of the knee (the lateral femoral condyle) or on the flat top of the lower leg bone (tibial plateau).</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">The exact cause of the osteonecrosis of the knee is not yet known. One theory is that a stress fracture, combined with a specific activity or trauma, results in an altered blood supply to the bone. Another theory supposes that a build-up of fluid within the bone puts pressure on blood vessels and diminishes circulation.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Osteonecrosis of the knee is also associated with certain conditions and treatments, such as obesity, sickle cell anemia, lupus, kidney transplants, and steroid therapy. Steroid-induced osteonecrosis frequently affects multiple joints and is usually seen in young patients.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Regardless of the cause, if the disease is not identified and treated early, it can develop into severe osteoarthritis.</span></div>
<div class="header1" style="background-color: white; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Symptoms" style="color: blue;"></a>Symptoms</span></div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span><ul style="background-color: white;">
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Sudden pain on the inside of the knee, perhaps triggered by a specific activity or minor injury</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Increased pain at night and with activity</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Swelling over the front and inside of the knee</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Heightened sensitivity to touch in the area</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Limited motion due to pain</span></li>
</ul>
<div class="header1" style="background-color: white; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Diagnosis" style="color: blue;"></a>Diagnosis</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Osteonecrosis of the knee develops through four stages, which can be identified by symptoms and X-rays.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Stage I: </strong>Symptoms are most intense in the earliest stage. Symptoms may continue for 6 to 8 weeks and then subside. Because X-rays are normal, a positive bone scan is needed to make the diagnosis. Treatment at this point is not surgical. The focus is on pain relief and protected weightbearing.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Stage II: </strong>It may take several months for the disease to progress to Stage II. At this point, X-rays will show that the rounded edge of the thighbone is starting to flatten out. An MRI or bone scan can be used to diagnose the disease. A computed tomography (CT) scan may also be used to measure the affected area.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Stage III:</strong> By the time the disease reaches stage III (3 to 6 months after onset), it is clearly visible on X-rays and no other diagnostic tests are needed. The articular cartilage covering the bone begins to loosen as the bone itself begins to die. Surgical treatments may be considered at this point.</span></div>
<div style="background-color: white;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Stage IV:</strong> At this point, the bone begins to collapse. The articular cartilage is destroyed, the joint space narrows, and bone spurs may form. Severe osteoarthritis results and joint replacement surgery may be necessary.</span></div>
<div class="header1" style="background-color: white; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Treatment" style="color: blue;"></a>Treatment</span></div>
<div style="background-color: white; margin-left: 20px; margin-right: 20px;">
<h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Nonsurgical Treatment</span></h4>
<div style="padding-top: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">In the early stages of the disease, treatment is not surgical. If the affected area is small, this treatment may be all that is needed.</span></div>
<span style="font-family: 'Trebuchet MS', sans-serif;">Options include:</span><br />
<ul>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Medications to reduce the pain</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">A brace to relieve pressure on the joint surface</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">A conditioning program with exercises to strengthen your thigh muscles</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Activity modifications to reduce knee pain</span></li>
</ul>
</div>
<div style="background-color: white; margin-left: 20px; margin-right: 20px;">
<h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Surgical Treatment</span></h4>
<div style="padding-top: 0px;">
<span style="font-family: 'Trebuchet MS', sans-serif;">If more than half of the bone surface is affected, you may need surgical treatment. Several different procedures may be used to treat osteonecrosis of the knee.</span></div>
<span style="font-family: 'Trebuchet MS', sans-serif;">Among the surgical options are:</span><br />
<ul>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Arthroscopic cleansing (debridement) of the joint</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Drilling to reduce pressure on the bone surface</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Procedures to shift weightbearing away from the affected area</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Unicompartmental or total knee replacement</span></li>
</ul>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;"><a href="http://orthoinfo.aaos.org/topic.cfm?topic=A00225" target="_blank">From the AAOS</a></span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div>
<span style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span></div>
</div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-25929172700771252762012-01-23T17:19:00.000-05:002012-01-23T17:19:05.831-05:00Post Arthroscopy Osteonecrosis of the Knee<div style="background-color: white; line-height: 21px; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Osteonecrosis is the death of bone tissue. There are three types of knee osteonecrosis: 1) spontaneous (occurs without a known cause), 2) post-</span><a class="alinks-link" href="http://www.eorthopod.com/content/arthroscopy" style="background-image: url(http://www.eorthopod.com/sites/all/modules/alinks/external.png); background-position: 100% 0%; background-repeat: no-repeat no-repeat; font-family: 'Trebuchet MS', sans-serif; outline-color: initial; outline-style: none; outline-width: initial; padding-right: 12px; text-decoration: none;" title="Arthroscopy">arthroscopy</a><span style="font-family: 'Trebuchet MS', sans-serif;"> </span><span style="font-family: 'Trebuchet MS', sans-serif;">(occurs after an arthroscopic procedure), and 3) secondary to some other condition such as</span><span style="font-family: 'Trebuchet MS', sans-serif;"> </span><a class="alinks-link" href="http://www.eorthopod.com/content/systemic-lupus-erythematosus" style="background-image: url(http://www.eorthopod.com/sites/all/modules/alinks/external.png); background-position: 100% 0%; background-repeat: no-repeat no-repeat; font-family: 'Trebuchet MS', sans-serif; outline-color: initial; outline-style: none; outline-width: initial; padding-right: 12px; text-decoration: none;" title="lupus">lupus</a><span style="font-family: 'Trebuchet MS', sans-serif;">, use of steroids, or alcohol abuse.</span></div><div style="background-color: white; line-height: 21px; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Spontaneous osteonecrosis of the knee is also referred to as <i>SPONK</i>. It usually occurs in one compartment or section of the knee, while secondary osteonecrosis (caused by disease or medical therapy) affects more than one compartment. The bottom, round part of the <i>femur</i>(thighbone) called the <i>femoral condyle</i> is affected most of the time.</span></div><div style="background-color: white; line-height: 21px; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Spontaneous osteonecrosis usually occurs in patients older than 55 years, while secondary osteonecrosis can occur at any age. Women are affected by SPONK three times more often than men. The reason for this is unknown.</span></div><div style="background-color: white; line-height: 21px; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Osteonecrosis of the knee is uncommon after arthroscopy. It usually occurs when some form of heat such as laser or other thermal devices were used during the procedure. The patient starts to develop worse pain after arthroscopy than before. Knee swelling is a common feature of this problem. (Dr. M comment: This is one reason that I never use these laser or thermal devices for knee arthroscopy. The other reason is that they are not necessary.)</span></div><div style="background-color: white; line-height: 21px; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">MRIs are relied upon to identify and diagnose osteonecrosis of the knee. In more advanced cases, a plain x-ray may reveal the problem. Bone scans are only reliable 56 per cent of the time. Osteonecrosis shows up on MRIs 100 per cent of the time. The main disadvantage of MRIs is the delay in findings after symptoms have started. Early on in the disease process, nothing unusual shows up on MRIs. The exact best timing for identifying this condition using MRIs remains unknown.</span></div><div style="background-color: white; line-height: 21px; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Once the condition has been diagnosed, then treatment begins. Everything is done to preserve the joint and prevent further breakdown of the bone. Early lesions can be treated conservatively (without surgery). The types of lesions that respond to nonoperative care have no low-density lines deep in the femoral condyles (as viewed on MRI scans) and no defects in the shape of the femoral condyles.</span></div><div style="background-color: white; line-height: 21px; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Patients are directed to avoid putting weight on the knee along with activity limitations. They must be patient as this protective process can take from three to eighteen months. Bone resorption may be stopped by the use of medications called <i>bisphosphonates</i>. Knee pain can be managed with <i>analgesics</i> (pain relievers). Treatment with bisphosphonates is fairly new and has not been proven effective for all patients yet. Further study of these drugs must be completed to guide the surgeon in knowing when and how to use bisphosphonates, as well as which patients would benefit the most.</span></div><div style="background-color: white; line-height: 21px; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Another newer drug treatment for knee osteonecrosis is <i>tumor necrosis factor alpha</i> (TNFA). This substance is injected right into the knee joint. Case reports show rapid (one-week later) improvement in pain and stiffness. Signs of healing are seen on MRIs after only one month.</span></div><div style="background-color: white; line-height: 21px; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">But when the case is too far advanced or when nonoperative care doesn't work, then surgery to repair the lesion may be needed. The type of surgery done depends on where the damage is located and how severe it is. The surgeon can drill holes in the bone, a procedure called <i>core decompression</i>. <i>Debridement</i> (scraping the damaged area) followed by bone grafting to replace the missing bone has also been tried.</span></div><div style="background-color: white; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 21px;">There haven't been very many cases treated with these various techniques. So, which one works best and for what types of knee osteonecrosis are also unknown factors. The most information we have is on the outcomes using </span><i style="line-height: 21px;">unicompartmental knee arthroplasty</i><span style="line-height: 21px;">. In this procedure, the surgeon replaces just the half of the joint that's been affected by the necrosis (rather than doing a full knee joint replacement). Some patients may require a total knee replacement if there is evidence of arthritis elsewhere in the knee or if the knee joint is malaligned due to arthritis or osteonecrosis.</span></span></div><div style="background-color: white; line-height: 21px; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Results reported from a limited number of studies report excellent results with this technique. Researchers consider the unilateral knee arthroplasty a very promising approach, but once again, more studies are needed to confirm these results and to see what happens in the long-run.</span></div><div style="background-color: white; line-height: 21px; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Right now, we only have limited information and understanding of what causes knee osteonecrosis and how to treat it. At the present time, research efforts are directed toward finding ways to preserve the joint, rather than replace it. Nonoperative treatments with new methods of tissue engineering may eventually provide a breakthrough in the treatment of this disease.</span></div><div style="background-color: white; line-height: 21px; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="background-color: white; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"></div><div align="justify" style="line-height: 19px; margin-bottom: 10px; margin-top: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Bisphosphonate treatment for knee osteonecrosis offered rapid pain relief and radiological consolidation of the osteonecrotic area, according to Swiss researchers.</span></div><div align="justify" style="line-height: 19px; margin-bottom: 10px; margin-top: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">In a prospective, researchers studied how bisphosphonate treatment affected 28 patients with spontaneous or arthroscopy-induced knee osteonecrosis. Patients had osteonecrotic lesions and bone marrow edema. Twenty-two patients developed osteonecrosis after knee arthroscopy, and six patients developed spontaneous osteonecrosis.</span></div><div align="justify" style="line-height: 19px; margin-bottom: 10px; margin-top: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">First, patients received 120 mg of intravenous pamidronate in three to four perfusions over a 2-week period, followed by 70 mg/day of the oral bisphosphonate alendronate for 4 to 6 months.</span></div><div align="justify" style="line-height: 19px; margin-bottom: 10px; margin-top: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><span style="text-align: left;">The results showed that bisphosphonate treatment was beneficial to patients. Bisphosphonate treatment quickly relieved pain, with Visual Analog Scores (VAS) dropping from 8.2 ± 1.2 at baseline to 5.02 ± 0.6 at 4 to 6 weeks postoperative (</span><i style="text-align: left;">P </i><span style="text-align: left;">< .001). The VAS decreased by 80% at 6 months (</span><i style="text-align: left;">P </i><span style="text-align: left;"><. 001). Fifteen of 28 patients had complete symptom resolution at 6 months follow-up; 6 patients had minimal symptoms (VAS 1 or 2).</span><span style="text-align: left;">Magnetic resonance imaging revealed that in 18 of 28 patients, bone marrow edema completely res</span><span style="text-align: left;">olved. The edema was significantly reduced in the remaining patients. In some cases, the researchers observed complete resolution of the osteonecrotic area; in others, they saw demarcation with sclerotic changes.</span></span></div><div align="justify" style="line-height: 19px; margin-bottom: 10px; margin-top: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Two patients had an unsatisfactory treatment effect; they both underwent arthroplasty.</span></div><div align="justify" style="margin-bottom: 10px; margin-top: 10px;"></div><div style="line-height: 19px; margin-bottom: 10px; margin-top: 10px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">The observations of the study are certainly consistent with the antiresorptive mechanism of bisphosphonates. In disorders of which the pathophysiology is dependent on turnover of bone or substantial osseous resorption, bisphosphonates present a potential therapeutic strategy.</span></div><div style="line-height: 19px; margin-bottom: 10px; margin-top: 10px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">However, without a true control group (as the authors note), this study does not rigorously show that the medication altered the natural history of the ON.</span></div><div style="line-height: 19px; margin-bottom: 10px; margin-top: 10px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="margin-bottom: 10px; margin-top: 10px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 19px;">I perform many knee arthroscopies (~150-200+) every year and have done so for 20 years. If we see a problem post-operatively, the most common problem we may see in patients with knee osteoarthritis, is a continuation or increase in their knee pain from the arthritis. The pain from their meniscus tear may be improved, but how the arthritis will respond to an arthroscopic surgery can be unpredictable. </span></span></div><div style="margin-bottom: 10px; margin-top: 10px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 19px;">Post knee arthroscopy osteonecrosis is more uncommon but below are some examples of my own patients over many years who have had this problem. They have, in turn, gone on to require a knee replacement with good results. </span></span></div><br />
<br />
<div class="separator" style="clear: both; text-align: center;"></div><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://2.bp.blogspot.com/-xDYsaEEeceM/Tx3We3kvmvI/AAAAAAAABEM/vz_N_qNuyC0/s1600/1.2.826.0.1.3680043.1.2.119.09120115.20110818.152403.0.0.3.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="273" src="http://2.bp.blogspot.com/-xDYsaEEeceM/Tx3We3kvmvI/AAAAAAAABEM/vz_N_qNuyC0/s320/1.2.826.0.1.3680043.1.2.119.09120115.20110818.152403.0.0.3.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: left;">Here is a standing x-ray of a patient pre-op. You can see that in his right knee there is some mild narrowing of the joint on the inside (medial side) of the knee. This is a result of early arthritis. His meniscus tear was causing pain, and an arthroscopy was performed to relieve that pain. He did well for many months after the surgery and came back with an increase in pain .</td></tr>
</tbody></table><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://3.bp.blogspot.com/-WjqB-Iopc7k/Tx3WgRDd6WI/AAAAAAAABEU/7jPmIqia0iA/s1600/1.2.826.0.1.3680043.1.2.119.09120115.20111129.161544.0.0.5.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="232" src="http://3.bp.blogspot.com/-WjqB-Iopc7k/Tx3WgRDd6WI/AAAAAAAABEU/7jPmIqia0iA/s320/1.2.826.0.1.3680043.1.2.119.09120115.20111129.161544.0.0.5.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: left;">Here is that patient's x-ray many months later showing loss of the medial joint space and collapse of the femoral condyle due to osteonecrosis. He is bone on bone with collapse of the medial joint.</td></tr>
</tbody></table><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://2.bp.blogspot.com/-lXeh4CfKzBU/Tx3WlN7BTwI/AAAAAAAABE0/TmjypPGrTMM/s1600/1.2.826.0.1.3680043.6.12654.20388.20101006133531.408.21451.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="289" src="http://2.bp.blogspot.com/-lXeh4CfKzBU/Tx3WlN7BTwI/AAAAAAAABE0/TmjypPGrTMM/s320/1.2.826.0.1.3680043.6.12654.20388.20101006133531.408.21451.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: left;">These are the x-rays of a second patient, who seemed to have no signs of any arthritis on the pre-op films before his knee arthroscopy. After the surgery, the pain from his meniscus tear was relieved for well over a year.</td></tr>
</tbody></table><div class="separator" style="clear: both; text-align: center;"><br />
</div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://2.bp.blogspot.com/-W6vwXrX5Uso/Tx3WmpjJrKI/AAAAAAAABE8/QJMzl9ULjN0/s1600/1.2.826.0.1.3680043.6.20776.16003.20110712095318.984.21913.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="271" src="http://2.bp.blogspot.com/-W6vwXrX5Uso/Tx3WmpjJrKI/AAAAAAAABE8/QJMzl9ULjN0/s320/1.2.826.0.1.3680043.6.20776.16003.20110712095318.984.21913.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: left;">Just over a year, from his knee arthroscopy, he returned in pain and a follow up x-ray was performed. It clearly shows collapse of the medial femoral condyle due to osteonecrosis. This patient, like the one above, went onto a knee replacement, with an excellent result. </td></tr>
</tbody></table><br />
<div class="separator" style="clear: both; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">So what's the point. </span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Under the best of circumstances, even with an experienced surgeon, a simple knee arthroscopy for a meniscus tear can have develop problems. While the risk of surgery, like a knee scope, is relatively low, the risk is never "zero". </span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">We do not really know what causes post arthroscopy osteonecrosis in these knees. </span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">The references for the science are below. The patients are mine.</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: center;"></div><div style="margin-bottom: 10px; margin-top: 10px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 19px;"><br />
</span></span></div><div style="margin-bottom: 10px; margin-top: 10px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 19px;"><br />
</span></span></div><div style="margin-bottom: 10px; margin-top: 10px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 19px;"><br />
</span></span></div><div style="margin-bottom: 10px; margin-top: 10px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 19px;"><br />
</span></span></div><br />
<br />
<div class="field field-type-text field-field-news-reference" style="background-color: white; line-height: 21px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><div class="field-label" style="font-weight: bold; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;">References: </span></div><div class="field-items" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><div class="field-item odd" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><div style="margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;">Maria S. Goddard, and Harpal S. Khanuja, MD. Special Focus. Knee Reconstruction. Osteonecrosis of the Knee. In Current Orthopaedic Practice. January/February 2009. Vol. 20. No. 1. Pp. 65-72.a</span></div><div style="margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"></div><div class="blue22bold" style="line-height: normal; margin-bottom: 4px; text-decoration: none;"><span style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;">Bisphosphonates may offer benefit for knee osteonecrosis</span></div><div class="grey14bold" style="line-height: normal; margin-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;">Kraenzlin ME, Graf C, Meier C, et al. <i>Knee Surg Sports Traumatol Arthrosoc</i>. DOI 10.1007/s00167-008-0673-0</span></div><br />
<div style="color: #333333; margin-bottom: 8px; margin-top: 8px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div></div></div></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-50167067448464581322012-01-19T15:47:00.000-05:002012-01-19T15:47:05.045-05:00Knee Replacement Surgery<div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">If your knee is severely damaged by arthritis or injury, it may be hard for you to perform simple activities, such as walking or climbing stairs. You may even begin to feel pain while you are sitting or lying down.</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">If nonsurgical treatments like medications and using walking supports are no longer helpful, you may want to consider total knee replacement surgery. Joint replacement surgery is a safe and effective procedure to relieve pain, correct leg deformity, and help you resume normal activities.</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Knee replacement surgery was first performed in 1968. Since then, improvements in surgical materials and techniques have greatly increased its effectiveness. Total knee replacements are one of the most successful procedures in all of medicine. According to the Agency for Healthcare Research and Quality, more than 600,000 knee replacements are performed each year in the United States.</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Whether you have just begun exploring treatment options or have already decided to have total knee replacement surgery, this article will help you understand more about this valuable procedure.</span></div><div class="header1" style="background-color: #f8f8f8; border-bottom-color: rgb(112, 141, 123); border-bottom-style: solid; border-bottom-width: 1px; color: #708d7b; font-weight: bold; margin-bottom: 5px; margin-left: 0px; margin-right: 0px; margin-top: 15px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; width: 356px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Anatomy" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;"></a>Anatomy</span></div><div class="figbox" style="background-color: #f8f8f8; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; color: #222222; float: none; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 10px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 300px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://testyoc.aaos.org/figures/A00389F01.jpg" style="clear: both; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Normal knee anatomy.</span></div></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">The knee is the largest joint in the body and having healthy knees is required to perform most everyday activities.</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">The knee is made up of the lower end of the thighbone (femur), the upper end of the shinbone (tibia), and the kneecap (patella). The ends of these three bones where they touch are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily.</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">The menisci are located between the femur and tibia. These C-shaped wedges act as "shock absorbers" that cushion the joint.</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Large ligaments hold the femur and tibia together and provide stability. The long thigh muscles give the knee strength.</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">All remaining surfaces of the knee are covered by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage, reducing friction to nearly zero in a healthy knee.</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Normally, all of these components work in harmony. But disease or injury can disrupt this harmony, resulting in pain, muscle weakness, and reduced function.</span></div><div class="header1" style="background-color: #f8f8f8; border-bottom-color: rgb(112, 141, 123); border-bottom-style: solid; border-bottom-width: 1px; color: #708d7b; font-weight: bold; margin-bottom: 5px; margin-left: 0px; margin-right: 0px; margin-top: 15px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; width: 356px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Cause" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;"></a>Cause</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">The most common cause of chronic knee pain and disability is arthritis. Although there are many types of arthritis, most knee pain is caused by just three types: osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis.</span></div><ul style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Osteoarthritis.</strong> This is an age-related "wear and tear" type of arthritis. It usually occurs in people 50 years of age and older, but may occur in younger people, too. The cartilage that cushions the bones of the knee softens and wears away. The bones then rub against one another, causing knee pain and stiffness.</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Rheumatoid arthritis.</strong> This is a disease in which the synovial membrane that surrounds the joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most common form of a group of disorders termed "inflammatory arthritis."</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Post-traumatic arthritis.</strong> This can follow a serious knee injury. Fractures of the bones surrounding the knee or tears of the knee ligaments may damage the articular cartilage over time, causing knee pain and limiting knee function.</span></li>
</ul><div class="figbox" style="background-color: #f8f8f8; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; color: #222222; float: none; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 10px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 400px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://testyoc.aaos.org/figures/A00389F02.jpg" style="clear: both; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Osteoarthritis often results in bone rubbing on bone. Bone spurs are a common feature of this form of arthritis.</span></div></div><div class="header1" style="background-color: #f8f8f8; border-bottom-color: rgb(112, 141, 123); border-bottom-style: solid; border-bottom-width: 1px; color: #708d7b; font-weight: bold; margin-bottom: 5px; margin-left: 0px; margin-right: 0px; margin-top: 15px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; width: 356px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Description" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;"></a>Description</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">A knee replacement (also called knee arthroplasty) might be more accurately termed a knee "resurfacing" because only the surface of the bones are actually replaced.</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">There are four basic steps to a knee replacement procedure.</span></div><ul style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Prepare the bone.</strong> The damaged cartilage surfaces at the ends of the femur and tibia are removed along with a small amount of underlying bone.</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Position the metal implants.</strong> The removed cartilage and bone is replaced with metal components that recreate the surface of the joint. These metal parts may be cemented or "press-fit" into the bone.</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Resurface the patella.</strong> The undersurface of the patella (kneecap) is cut and resurfaced with a plastic button. Some surgeons do not resurface the patella, depending upon the case.</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Insert a spacer.</strong> A medical-grade plastic spacer is inserted between the metal components to create a smooth gliding surface.</span></li>
</ul><div class="figbox" style="background-color: #f8f8f8; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; color: #222222; float: none; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 10px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 400px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://testyoc.aaos.org/figures/A00389F03.jpg" style="clear: both; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">(Left)</strong> Severe osteoarthritis. <strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">(Right)</strong> The arthritic cartilage and underlying bone has been removed and resurfaced with metal implants on the femur and tibia. A plastic spacer has been placed in between the implants. The patellar component is not shown for clarity.</span></div></div><div class="header1" style="background-color: #f8f8f8; border-bottom-color: rgb(112, 141, 123); border-bottom-style: solid; border-bottom-width: 1px; color: #708d7b; font-weight: bold; margin-bottom: 5px; margin-left: 0px; margin-right: 0px; margin-top: 15px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; width: 356px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Is Total Knee Replacement for You?" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;"></a>Is Total Knee Replacement for You?</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">The decision to have total knee replacement surgery should be a cooperative one between you, your family, your family physician, and your orthopaedic surgeon. Your physician may refer you to an orthopaedic surgeon for a thorough evaluation to determine if you might benefit from this surgery.</span></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">When Surgery Is Recommended</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">There are several reasons why your doctor may recommend knee replacement surgery. People who benefit from total knee replacement often have:</span></div><div class="figbox" style="background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: right; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 10px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 150px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://testyoc.aaos.org/figures/A00389F07.jpg" style="clear: both; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">A knee that has become bowed as a result of severe arthritis.</span></div></div><ul style="margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Severe knee pain or stiffness that limits your everyday activities, including walking, climbing stairs, and getting in and out of chairs. You may find it hard to walk more than a few blocks without significant pain and you may need to use a cane or walker</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Moderate or severe knee pain while resting, either day or night</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Chronic knee inflammation and swelling that does not improve with rest or medications</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Knee deformity — a bowing in or out of your knee</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Failure to substantially improve with other treatments such as anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy, or other surgeries</span></li>
</ul></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Candidates for Surgery</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">There are no absolute age or weight restrictions for total knee replacement surgery.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Recommendations for surgery are based on a patient's pain and disability, not age. Most patients who undergo total knee replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total knee replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.</span></div></div><div class="header1" style="background-color: #f8f8f8; border-bottom-color: rgb(112, 141, 123); border-bottom-style: solid; border-bottom-width: 1px; color: #708d7b; font-weight: bold; margin-bottom: 5px; margin-left: 0px; margin-right: 0px; margin-top: 15px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; width: 356px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Orthopaedic Evaluation" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;"></a>Orthopaedic Evaluation</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">An evaluation with an orthopaedic surgeon consists of several components:</span></div><ul style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">A medical history.</strong> Your orthopaedic surgeon will gather information about your general health and ask you about the extent of your knee pain and your ability to function.</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">A physical examination.</strong> This will assess knee motion, stability, strength, and overall leg alignment.</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">X-rays.</strong> These images help to determine the extent of damage and deformity in your knee.</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Other tests.</strong> Occasionally blood tests, or advanced imaging such as a magnetic resonance imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues of your knee.</span></li>
</ul><div class="figbox" style="background-color: #f8f8f8; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; color: #222222; float: none; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 10px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 300px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://testyoc.aaos.org/figures/A00389F04.jpg" style="clear: both; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">(Left)</strong> In this x-ray of a normal knee, the space between the bones indicates healthy cartilage (arrow). <strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">(Right)</strong> This x-ray of an arthritic knee shows severe loss of joint space and bone spurs (arrows).</span></div></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether total knee replacement is the best method to relieve your pain and improve your function. Other treatment options — including medications, injections, physical therapy, or other types of surgery — will also be considered and discussed.</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">In addition, your orthopaedic surgeon will explain the potential risks and complications of total knee replacement, including those related to the surgery itself and those that can occur over time after your surgery.</span></div><div class="header1" style="background-color: #f8f8f8; border-bottom-color: rgb(112, 141, 123); border-bottom-style: solid; border-bottom-width: 1px; color: #708d7b; font-weight: bold; margin-bottom: 5px; margin-left: 0px; margin-right: 0px; margin-top: 15px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; width: 356px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Deciding to Have Knee Replacement Surgery" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;"></a>Deciding to Have Knee Replacement Surgery</span></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Realistic Expectations</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">An important factor in deciding whether to have total knee replacement surgery is understanding what the procedure can and cannot do.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">More than 90% of people who have total knee replacement surgery experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living. But total knee replacement will not allow you to do more than you could before you developed arthritis.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">With normal use and activity, every knee replacement implant begins to wear in its plastic spacer. Excessive activity or weight may speed up this normal wear and may cause the knee replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports for the rest of your life after surgery.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Realistic activities following total knee replacement include unlimited walking, swimming, golf, driving, light hiking, biking, ballroom dancing, and other low-impact sports.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">With appropriate activity modification, knee replacements can last for many years.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Possible Complications of Surgery</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">The complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in fewer than 2% of patients. Major medical complications such as heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur, they can prolong or limit full recovery.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.</span></div><div class="figbox" style="background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: right; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 10px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 250px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://testyoc.aaos.org/figures/A00389F08.jpg" style="clear: both; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Blood clots may develop in leg veins.</span></div></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Infection.</strong> Infection may occur in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Blood clots.</strong> Blood clots in the leg veins are the most common complication of knee replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program, which may include periodic elevation of your legs, lower leg exercises to increase circulation, support stockings, and medication to thin your blood.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Implant problems.</strong> Although implant designs and materials, as well as surgical techniques, continue to advance, implant surfaces may wear down and the components may loosen. Additionally, although an average of 115° of motion is generally anticipated after surgery, scarring of the knee can occasionally occur, and motion may be more limited, particularly in patients with limited motion before surgery.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Continued pain.</strong> A small number of patients continue to have pain after a knee replacement. This complication is rare, however, and the vast majority of patients experience excellent pain relief following knee replacement.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Neurovascular injury.</strong> While rare, injury to the nerves or blood vessels around the knee can occur during surgery.</span></div></div><div class="header1" style="background-color: #f8f8f8; border-bottom-color: rgb(112, 141, 123); border-bottom-style: solid; border-bottom-width: 1px; color: #708d7b; font-weight: bold; margin-bottom: 5px; margin-left: 0px; margin-right: 0px; margin-top: 15px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; width: 356px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Preparing for Surgery" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;"></a>Preparing for Surgery</span></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Medical Evaluation</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">If you decide to have total knee replacement surgery, your orthopaedic surgeon may ask you to schedule a complete physical examination with your family physician several weeks before the operation. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such as a cardiologist, before the surgery.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Tests</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Several tests, such as blood and urine samples, and an electrocardiogram, may be needed to help your orthopaedic surgeon plan your surgery.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Medications</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Tell your orthopaedic surgeon about the medications you are taking. He or she will tell you which medications you should stop taking and which you should continue to take before surgery.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Dental Evaluation</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Although the incidence of infection after knee replacement is very low, an infection can occur if bacteria enter your bloodstream. To reduce the risk of infection, major dental procedures (such as tooth extractions and periodontal work) should be completed before your total knee replacement surgery.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Urinary Evaluations</span></h4><span style="font-family: 'Trebuchet MS', sans-serif;">People with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before undertaking knee replacement surgery.</span></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Social Planning</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Although you will be able to walk on crutches or a walker soon after surgery, you will need help for several weeks with such tasks as cooking, shopping, bathing, and doing laundry.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">If you live alone, your orthopaedic surgeon's office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at home. They also can help you arrange for a short stay in an extended care facility during your recovery, if this option works best for you.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Home Planning</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:</span></div><ul style="margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Safety bars or a secure handrail in your shower or bath</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Secure handrails along your stairways</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">A stable chair for your early recovery with a firm seat cushion (and a height of 18 to 20 inches), a firm back, two arms, and a footstool for intermittent leg elevation</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">A toilet seat riser with arms, if you have a low toilet</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">A stable shower bench or chair for bathing</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Removing all loose carpets and cords</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">A temporary living space on the same floor because walking up or down stairs will be more difficult during your early recovery</span></li>
</ul></div><div class="header1" style="background-color: #f8f8f8; border-bottom-color: rgb(112, 141, 123); border-bottom-style: solid; border-bottom-width: 1px; color: #708d7b; font-weight: bold; margin-bottom: 5px; margin-left: 0px; margin-right: 0px; margin-top: 15px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; width: 356px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Your Surgery" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;"></a>Your Surgery</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">You will most likely be admitted to the hospital on the day of your surgery.</span></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Anesthesia</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">After admission, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anesthesia (you are awake but your body is numb from the waist down). The anesthesia team, with your input, will determine which type of anesthesia will be best for you.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Procedure</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">The procedure itself takes approximately 1 to 2 hours. Your orthopaedic surgeon will remove the damaged cartilage and bone, and then position the new metal and plastic implants to restore the alignment and function of your knee.</span></div><div class="figbox" style="background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: none; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 10px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 250px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://testyoc.aaos.org/figures/A00389F09.jpg" style="clear: both; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Different types of knee implants are used to meet each patient's individual needs.</span></div></div><div class="figbox" style="background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: none; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 10px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 300px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://testyoc.aaos.org/figures/A00389F05.jpg" style="clear: both; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">(Left)</strong> An x-ray of a severely arthritic knee. <strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">(Right)</strong> The x-ray appearance of a total knee replacement. Note that the plastic spacer between the bones does not show up in an x-ray.</span></div></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">After surgery, you will be moved to the recovery room, where you will remain for several hours while your recovery from anesthesia is monitored. After you wake up, you will be taken to your hospital room.</span></div></div><div class="header1" style="background-color: #f8f8f8; border-bottom-color: rgb(112, 141, 123); border-bottom-style: solid; border-bottom-width: 1px; color: #708d7b; font-weight: bold; margin-bottom: 5px; margin-left: 0px; margin-right: 0px; margin-top: 15px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; width: 356px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Your Hospital Stay" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;"></a>Your Hospital Stay</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">You will most likely stay in the hospital for several days.</span></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Pain Management</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">After surgery, you will feel some pain, but your surgeon and nurses will provide medication to make you feel as comfortable as possible. Pain management is an important part of your recovery. Walking and knee movement will begin soon after surgery, and when you feel less pain, you can start moving sooner and get your strength back more quickly. Talk with your surgeon if postoperative pain becomes a problem.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Blood Clot Prevention</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Your orthopaedic surgeon may prescribe one or more measures to prevent blood clots and decrease leg swelling. These may include special support hose, inflatable leg coverings (compression boots), and blood thinners.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Foot and ankle movement also is encouraged immediately following surgery to increase blood flow in your leg muscles to help prevent leg swelling and blood clots.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Physical Therapy</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
To restore movement in your knee and leg, your surgeon may use a knee support that slowly moves your knee while you are in bed. The device, called a continuous passive motion (CPM) exercise machine, decreases leg swelling by elevating your leg and improves your blood circulation by moving the muscles of your leg. In many cases, I have found to be unnecessary and studies demonstrate that the initial use of a CPM will not affect long term motion of the knee. </span><span style="font-family: 'Trebuchet MS', sans-serif;">Most patients begin exercising their knee the day after surgery. A physical therapist will teach you specific exercises to strengthen your leg and restore knee movement to allow walking and other normal daily activities soon after your surgery.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Preventing Pneumonia</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">It is common for patients to have shallow breathing in the early postoperative period. This is usually due to the effects of anesthesia, pain medications, and increased time spent in bed. This shallow breathing can lead to a partial collapse of the lungs (termed "atelectasis") which can make patients susceptible to pneumonia. To help prevent this, it is important to take frequent deep breaths. Your nurse may provide a simple breathing apparatus called a spirometer to encourage you to take deep breaths.</span></div></div><div class="header1" style="background-color: #f8f8f8; border-bottom-color: rgb(112, 141, 123); border-bottom-style: solid; border-bottom-width: 1px; color: #708d7b; font-weight: bold; margin-bottom: 5px; margin-left: 0px; margin-right: 0px; margin-top: 15px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; width: 356px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Your Recovery at Home" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;"></a>Your Recovery at Home</span></div><div style="background-color: #f8f8f8; color: #222222; margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">The success of your surgery will depend largely on how well you follow your orthopaedic surgeon's instructions at home during the first few weeks after surgery.</span></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Wound Care</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">You will have stitches or staples running along your wound or a suture beneath your skin on the front of your knee. The stitches or staples will be removed several weeks after surgery. A suture beneath your skin will not require removal.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Avoid soaking the wound in water until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Diet</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to help your wound heal and to restore muscle strength.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Activity</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal activities of daily living within 3 to 6 weeks following surgery. Some pain with activity and at night is common for several weeks after surgery.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Your activity program should include:</span></div><ul style="margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">A graduated walking program to slowly increase your mobility, initially in your home and later outside</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Resuming other normal household activities, such as sitting, standing, and climbing stairs</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Specific exercises several times a day to restore movement and strengthen your knee. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home or in a therapy center the first few weeks after surgery.</span></li>
</ul><div class="figbox" style="background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: none; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 10px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 200px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://testyoc.aaos.org/figures/A00389F10.jpg" style="clear: both; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></span><div style="color: #660000; font-style: italic; margin-bottom: 0px; margin-left: 5px; margin-right: 5px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">Thinkstock © 2011</span></div></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">You will most likely be able to resume driving when your knee bends enough that you can enter and sit comfortably in your car, and when your muscle control provides adequate reaction time for braking and acceleration. Most people resume driving approximately 4 to 6 weeks after surgery.</span></div></div><div class="header1" style="background-color: #f8f8f8; border-bottom-color: rgb(112, 141, 123); border-bottom-style: solid; border-bottom-width: 1px; color: #708d7b; font-weight: bold; margin-bottom: 5px; margin-left: 0px; margin-right: 0px; margin-top: 15px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; width: 356px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Avoiding Problems After Surgery" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;"></a>Avoiding Problems After Surgery</span></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Blood Clot Prevention</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Follow your orthopaedic surgeon's instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He or she may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Warning signs of blood clots.</strong> The warning signs of possible blood clots in your leg include:</span></div><ul style="margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Increasing pain in your calf</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Tenderness or redness above or below your knee</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Increasing swelling in your calf, ankle, and foot</span></li>
</ul><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Warning signs of pulmonary embolism.</strong> The warning signs that a blood clot has traveled to your lung include:</span></div><ul style="margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Sudden shortness of breath</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Sudden onset of chest pain</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Localized chest pain with coughing</span></li>
</ul></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Preventing Infection</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">A common cause of infection following total knee replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around your knee replacement and cause an infection.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">After your knee replacement, you must take preventive antibiotics before dental or surgical procedures that could allow bacteria to enter your bloodstream.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Warning signs of infection.</strong> Notify your doctor immediately if you develop any of the following signs of a possible knee replacement infection:</span></div><ul style="margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Persistent fever (higher than 100°F orally)</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Shaking chills</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Increasing redness, tenderness, or swelling of the knee wound</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Drainage from the knee wound</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Increasing knee pain with both activity and rest</span></li>
</ul></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Avoiding Falls</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">A fall during the first few weeks after surgery can damage your new knee and may result in a need for further surgery. Stairs are a particular hazard until your knee is strong and mobile. You should use a cane, crutches, a walker, hand rails, or have someone to help you until you have improved your balance, flexibility, and strength.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Your surgeon and physical therapist will help you decide what assistive aides will be required following surgery and when those aides can safely be discontinued.</span></div></div><div class="header1" style="background-color: #f8f8f8; border-bottom-color: rgb(112, 141, 123); border-bottom-style: solid; border-bottom-width: 1px; color: #708d7b; font-weight: bold; margin-bottom: 5px; margin-left: 0px; margin-right: 0px; margin-top: 15px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; width: 356px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Outcomes" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;"></a>Outcomes</span></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">How Your New Knee Is Different</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Improvement of knee motion is a goal of total knee replacement, but restoration of full motion is uncommon. The motion of your knee replacement after surgery can be predicted by the range of motion you have in your knee before surgery. Most patients can expect to be able to almost fully straighten the replaced knee and to bend the knee sufficiently to climb stairs and get in and out of a car. Kneeling is sometimes uncomfortable, but it is not harmful. It is usually advisable to avoid kneeling directly on the knee cap as this can damage the bone (creating a fracture) or the connection between the knee cap bone and the plastic joint surface.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Most people feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending activities.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Most people also feel or hear some clicking of the metal and plastic with knee bending or walking. This is a normal. These differences often diminish with time and most patients find them to be tolerable when compared with the pain and limited function they experienced prior to surgery.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">It can take a year or more for you to reach maximum benefit from your knee replacement. While the joint surface is replaced and no longer causes pain, the tendons, ligaments and other soft tissues around the knee can be sore and painful for about a year. Most patients can return to light work at about 2-3 months depending on their pace of recovery. Every patient is different. </span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Your new knee may activate metal detectors required for security in airports and some buildings. Tell the security agent about your knee replacement if the alarm is activated.</span></div></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Protecting Your Knee Replacement</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">After surgery, make sure you also do the following:</span></div><ul style="margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Participate in regular light exercise programs to maintain proper strength and mobility of your new knee.</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery.</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Make sure your dentist knows that you have a knee replacement. You should be given antibiotics before all dental surgery for the rest of your life.</span></li>
<li style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.7em; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">See your orthopaedic surgeon periodically for a routine follow-up examination and x-rays, usually once a year for the first 2 years and then every other year after that.</span></li>
</ul></div><div class="indent" style="background-color: #f8f8f8; color: #222222; margin-bottom: 0px; margin-left: 20px; margin-right: 20px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><h4 style="color: #77786a; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Extending the Life of Your Knee Implant</span></h4><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Currently, more than 90% of modern total knee replacements are still functioning well 15 years after the surgery. Following your orthopaedic surgeon's instructions after surgery and taking care to protect your knee replacement and your general health are important ways you can contribute to the final success of your surgery.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Here is a <a href="http://orthoontheweb.com/knee_replacement.asp" target="_blank">link </a>to other knee replacement information on my web site.</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;"><a href="http://www.saveyourknees.org/print.cfm?topic=A00389" target="_blank">Reference</a></span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br />
</div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="margin-bottom: 1em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span></div></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-61477535934809403212012-01-19T15:17:00.000-05:002012-01-19T15:17:16.108-05:00Wrist Fractures<span style="font-family: 'Trebuchet MS', sans-serif;">The radius is the larger of the two bones of the forearm. The end toward the wrist is called the distal end. A fracture of the distal radius occurs when the area of the radius near the wrist breaks.</span><br />
<br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 342px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Cause" style="color: blue;"></a>Cause</span></div><br />
<div class="figbox" style="background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: right; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 20px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 310px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00412F03.jpg" style="clear: both;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; text-align: left;"></div><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"></div></div><span style="font-family: 'Trebuchet MS', sans-serif;">Distal radius fractures are very common. In fact, the radius is the most commonly broken bone in the arm. The break usually happens when a fall causes someone to land on their outstretched hands. It can also happen in a car accident, a bike accident, a skiing accident, and similar situations.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Sometimes, the other bone of the forearm (the ulna) is also broken. When this happens, it is called a distal ulna fracture.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">This fracture was first described by an Irish surgeon and anatomist, Abraham Colles, in 1814; hence the name, "Colles " fracture.</span><br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 342px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Symptoms" style="color: blue;"></a>Symptoms</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">A broken wrist usually causes immediate (acute) pain, tenderness, bruising, and swelling. Frequently, the wrist hangs in an odd or bent way (deformity).</span><br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 342px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Diagnosis" style="color: blue;"></a>Diagnosis</span></div><br />
<div class="figbox" style="background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: right; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 20px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 310px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00412F02.jpg" style="clear: both;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; text-align: left;"></div><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"></div></div><span style="font-family: 'Trebuchet MS', sans-serif;">The doctor will take an X-ray of the wrist. This is important to understand the extent of the injury.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">The fracture almost always occurs about 1 inch from the end of the bone. The break (fracture) can occur in many different ways, however.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">A fracture that extends into the joint, it is called an intra-articular fracture.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">A fracture that does not extend into the joint is called an extra-articular fracture. ("Articular" means "joint.")</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">When a fractured bone breaks the skin, it is called an open fracture.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">When a bone is broken into more than two pieces, it is called a comminuted fracture.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">It is important to classify the type of fracture, because some fractures are more difficult to treat than others. Intra-articular fractures (fractures within the joints), open fractures (fractures that break through the skin), and comminuted fractures (fracture that shatter the bone into a lot of small pieces) are more difficult to treat, for example.</span><br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 342px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Risk Factors" style="color: blue;"></a>Risk Factors</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">Osteoporosis (decreased density of the bones) can make a relatively minor fall result in a broken wrist. Many distal radius fractures in people older than 60 years of age are caused by a fall from a standing position.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">A broken wrist can happen even in healthy bones, if the force of the trauma is severe enough. For example, a car accident or a fall off a bike may generate enough force to break a wrist.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Good bone health remains an important prevention option. Wrist guards may help to prevent some fractures, but they will not prevent them all.</span><br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 342px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Treatment" style="color: blue;"></a>Treatment</span></div><div style="margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Immediate Treatment</span></h4><div style="padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">If the injury is not very painful and the wrist is not deformed, it may be possible to wait until the next day. The wrist may be protected with a splint. An ice pack can be applied to the wrist and the wrist can be elevated until the doctor is able to examine it.</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">If the injury is very painful, if the wrist is deformed or numb or the fingers are not pink, it is necessary to go to the emergency room.</span></div><div style="margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Nonsurgical Treatment</span></h4><div style="padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">There are many treatment choices. The choice depends on many factors, such as the nature of the fracture, age and activity level, and surgeon's personal preferences. The following is a general discussion of the possible options.</span></div><span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Casting:</strong> If the broken bone is in a good position, a plaster cast may be applied until the bone heals.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">If the position (alignment) of your bone is not good and likely to limit the future use of the arm, it may be necessary to correct the deformity. The bone would be re-aligned (reduced).</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">If the bone is straightened (reduced) without having to open the skin (incision), this is called a closed reduction.</span><br />
<br />
<div class="figbox" style="background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: right; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 20px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 310px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00412F04.jpg" style="clear: both;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; text-align: left;"></div><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"></div></div><span style="font-family: 'Trebuchet MS', sans-serif;">After the bone is properly aligned, a splint or cast may be placed on your arm. A splint is usually used for the first few days, to allow for a small amount of normal swelling. A cast is usually added a few days to a week or so later, after the swelling goes down. The cast is changed two or three weeks later as the swelling goes down more, causing the cast to loosen.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">X-rays may be taken, depending on the nature of the fracture. X-rays may be taken at weekly intervals for three weeks and then at six weeks if the fracture was reduced or thought to be unstable. X-rays may be taken less often if the fracture was not reduced and thought to be stable.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">The cast is removed about six weeks after the fracture happened. At that point, physical therapy is often started to help improve the motion and function of the injured wrist.</span></div><div style="margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Surgical Treatment</span></h4><div style="padding-top: 0px;"></div><div class="figbox" style="background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: right; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 20px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 310px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00412F05.jpg" style="clear: both;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; text-align: left;"></div><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"></div></div><span style="font-family: 'Trebuchet MS', sans-serif;">Sometimes, the position of the bone is so much out of place that it cannot be corrected or kept corrected in a cast. This has the potential of interfering with the future functioning of your arm. In this case, surgery may be required.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">There are many ways of performing surgery. Even if the fracture is treated in the operating room, it may be possible to re-align (reduce) the fracture without making an incision (closed reduction). In other cases, it will be necessary to make an incision (open reduction) to directly access the broken bones to improve alignment.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Depending on the fracture, there are a number of options for holding the bone in the correct position, including a cast, metal pins (usually stainless steel or titanium), a plate and screws, an external fixator (a device for which most of the hardware remains outside of the body), or any combination of these techniques.</span></div><div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 342px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="After Surgery" style="color: blue;"></a>After Surgery</span></div><div style="margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">What can I expect while my bone is healing?</span></h4><div style="padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">The kinds of distal radius fractures are so varied and the treatment options are so broad that it is hard to generalize what to expect.</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">Most fractures hurt moderately for a few days to a couple of weeks. Many patients find that using ice, elevation (holding their arm up above their heart), and simple, non-prescription medications for pain relief are all that are needed.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">One combination is ibuprofen plus acetaminophen ("non-aspirin pain reliever"). The combination of both ibuprofen plus acetaminophen is much more effective than either one alone. If pain is severe, patients may need to take a prescription strength medication, often a narcotic, for a few days.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Casts and splints must be kept dry. A plastic bag over the arm while showering should help. If the cast does become wet, it will not dry very easily. A hair dryer on the cool setting may be helpful.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Most surgical incisions must be kept clean and dry for five days or until the sutures (stitches) are removed, whichever occurs later.</span></div><div style="margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">What can I expect after my bone has healed?</span></h4><div style="padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Most patients do return to all their former activities. The nature of the injury, the kind of treatment received, and the body's response to the treatment all have an impact, so the answer is different for each individual.</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">Some generalizations can be made.</span><br />
<ul><li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">The cast is usually removed at about six weeks.</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Most patients will start physical therapy, if their doctor feels it is needed, within a few days to weeks after surgery, or right after the last cast is taken off.</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Most patients will be able to resume light activities, such as swimming or exercising the lower body in the gym, within a month or two after the cast is taken off or after within a month or two after surgery.</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Most patients can resume vigorous physical activities, such as skiing or football, between three and six months after the injury.</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Almost all patients will have some stiffness in the wrist, which will generally lessen in the month or two after the cast is taken off or after surgery. Improvement will continue for at least two years.</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Recovery should be expected to take at least a year. Some pain with vigorous activities may be expected for about that long. Some residual stiffness or ache is to be expected for two years or possibly permanently, especially for high-energy injuries (such as motorcycle crashes, etc), in patients older than 50 years of age, or in patients who have some osteoarthritis. However, the stiffness is usually minor and may not affect the overall function of the arm.</span></li>
</ul></div><span style="font-family: 'Trebuchet MS', sans-serif;">Remember, these are general guidelines and may not apply to you and your fracture. Ask us for specifics in your case. </span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Finally, osteoporosis is a factor in as many as 250,000 wrist fractures. It has been suggested that people who suffer a wrist fracture may need to be screened for osteoporosis, especially if they have other risk factors. Ask Dr. Mazzara or your medical doctor if you need to be screened or treated for osteoporosis.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;">From the <a href="http://orthoinfo.aaos.org/topic.cfm?topic=A00412" target="_blank">AAOS</a></span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">If you go <a href="http://orthoontheweb.com/wrist.asp" target="_blank">here </a>on my web site, you can learn more about wrist fractures and how they can be repaired by viewing the animations on this web page.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-84518551926439392282012-01-19T15:04:00.000-05:002012-01-19T15:04:03.356-05:00Starting a Strength Training Program<span style="font-family: 'Trebuchet MS', sans-serif;">Exercise programs that get the best results are made up of three main elements: aerobic conditioning, flexibility exercises, and strength training.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">In strength training, resistance is added to movement in order to make muscles work harder and, over time, become stronger. The most common strength training methods include using weight machines, working with free weights, or doing exercises that use your own body weight (push-ups, for example).</span><br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="The Benefits of Strength Training" style="color: blue;"></a>The Benefits of Strength Training</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">Strength training increases muscle tone, strength, and endurance, as well as bone strength. Being stronger improves your balance and coordination, reduces your risk for injury, and also makes it easier to do daily activities like carrying groceries and doing yard work.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">As we age, we naturally begin to lose muscle mass, which slows down metabolism. Having more muscle mass helps your body burn more calories when at rest. Increasing your muscle mass with strength training is an important element of a weight management program.</span><br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Strength Training Equipment" style="color: blue;"></a>Strength Training Equipment</span></div><div class="figbox" style="background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: right; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 20px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 150px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00331F01.jpg" style="clear: both;" /></span><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">© 2012 Thinkstock</span></div></div><span style="font-family: 'Trebuchet MS', sans-serif;">Strength training is typically done with free weights and weight machines. Both are effective ways to improve muscle strength and endurance.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Free weights are less expensive than weight machines and are more easily adapted to different body types. Free weight programs often include using dumbbells, a bar bell, and a weight bench.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Weight machines are generally safer than most free weights because your body positioning and the weight you are lifting are more controlled. There are different types of multipurpose weight machines, but many machines focus on strengthening just one specific muscle group.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Strength training programs can also be enhanced with other tools, such as resistance tubing, stability balls, as well as exercises that use your own body weight for resistance.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">I usually advise patients to start with resistance tubing exercises especially if they are recovering from a joint or tendon injury. The trauma to the joint is less with properly used resistance bands and they are inexpensive and available at any sporting goods store or even online. </span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Different types of equipment make your muscles work differently, so following a program that uses a variety of strength equipment may provide better results, as well as help you stay motivated to exercise.</span><br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Beginning a Strength Training Program" style="color: blue;"></a>Beginning a Strength Training Program</span></div><div style="margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Exercise Safety</span></h4><div style="padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">If you have a chronic health condition, are overweight, a smoker, or are middle aged or older and have never exercised, check with your doctor before starting any exercise program.</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">Strengthening exercises provide many health benefits, but when you do them incorrectly, you are at risk for injury. If you are a member of a health club, ask a fitness professional to show you how to safely use the weight machines and free weights. For many people, a group fitness class is also a good option for learning strength exercises and performing them correctly.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Some people prefer exercising at home. If you plan on this, it is a good idea to schedule a few sessions with a certified personal trainer to make sure you know how to do the exercises correctly. An exercise professional can also help you design a strengthening program that will meet your needs. Home exercise videos are another way to combat exercise boredom and maintain proper form and technique.</span></div><div style="margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">An Effective Strength Program</span></h4><div style="padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">A general guideline for improving strength is to exercise each major muscle group at least twice a week. For example, you could focus on total body strength training two days out of the week, or you could break it up by doing your lower body and upper body on alternate days.</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">Be sure to rest the muscle group you have worked (shoulders, for example) for a full day in between strength sessions for that muscle group. So, if you prefer total body strength training, the day after your strength train day should be either a rest or aerobic conditioning day.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Your program should include exercises for all of the major muscle groups. Muscle imbalances are a major cause of injury.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Three sets of 12 repetitions has long been the standard for effective strength training, and is still a helpful guideline. But if finding time to exercise is a challenge, you may be able to improve your strength with fewer repetitions. Recent research shows that most people see results from one set of 12 to 15 repetitions, as long as they are pushing their muscles to fatigue.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Regardless of the number of sets, be sure to choose a weight that is heavy enough to fatigue your muscles in 12 to 15 repetitions. As the exercise becomes easier, gradually increase the level of resistance.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">As you become stronger, it may become more difficult to measure the strength gains you make. Try adding new exercises or equipment to your regimen to keep your strength workouts fresh, engaging, and effective.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;">From the <a href="http://orthoinfo.aaos.org/topic.cfm?topic=A00331" target="_blank">AAOS</a></span><br />
<br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-24507140526979404362012-01-19T14:57:00.000-05:002012-01-19T14:57:24.567-05:00Starting an Exercise program<span style="font-family: 'Trebuchet MS', sans-serif;">The toughest and most important step in an exercise program is getting started. People often try to tackle a strenuous program right away thinking it will bring results faster. But if it has been a long time since you have exercised, slow and steady is the most effective and safest way to begin.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">You need a workable plan to change your lifestyle from sedentary to physically active. If you have an existing health problem, such as high blood pressure, diabetes, a history of heart disease, or are a smoker, you should contact your doctor before beginning any vigorous physical activity.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Following some basic guidelines can help you establish an exercise program that protects you against disease and disability and insures a healthy, independent, and productive life.</span><br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Prepare for Success" style="color: blue;"></a>Prepare for Success</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">Your goal is to establish an exercise routine you enjoy. Make sure your first activity sessions are fun and not tiring. Give your body a chance to get used to it.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Take plenty of time to warm up and cool down with walking and gentle stretching exercises.</span><br />
<div style="margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Selecting Exercise Activities</span></h4><div class="figbox" style="background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-image: initial; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: right; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 20px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 150px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00416F01.jpg" style="clear: both;" /></span><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"><span style="font-family: 'Trebuchet MS', sans-serif;">© 2012 Thinkstock</span></div></div><div style="padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Some people prefer exercising at home. This is more economical and convenient than joining a fitness club or taking exercise classes. To be successful exercising at home, however, you must be self-motivated in order to stick with your program.</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">Exercising at a fitness club is a good choice for those who like the stimulation of being with others and having the range of exercise options — machines, fitness classes, personal trainers — that a club provides. It is, however, a greater expense than exercising at home.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Whether exercising at home or at a gym, choose activities that can be practiced comfortably year round. Try to have both indoor and outdoor exercise options. That way the weather or boredom will not be easy excuses for skipping your workout.</span></div><div style="margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Ensuring Proper Equipment</span></h4><div style="padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Shoes.</strong> Proper-fitting sports shoes can enhance athletic performance and prevent injuries. Wear athletic shoes that are comfortable, provide good support, and do not cause blisters or calluses. It is helpful to purchase your shoes from a store that has salespeople who are knowledgeable about athletic shoes and different foot types.</span></div><span style="font-family: 'Trebuchet MS', sans-serif;"><strong>Home equipment.</strong> If your plan is to set up a workout area in your home, be sure to try out any equipment before you purchase it. This can be done in the store or at a local fitness center. Libraries and video rental services have a wide range of exercise videos that you can try before purchasing, as well.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><strong>New technology.</strong> There are a wide range of new products that can enhance your fitness routine, if you are motivated by technology. Fitness apps for smart devices have become very popular. For example, fitness apps can provide new running/walking routes, track your distance, or show you new exercises.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">A simple heart rate monitor measures your heart rate during exercise and helps you track your progress as your cardiovascular fitness improves. Newer devices can track other data — such as calories burned — and also provide training plans and serve as daily training logs.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Exercise video games are also an option for some people. The more strenuous video games can also improve your fitness, as long as you do them actively.</span></div><div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="A Balanced Exercise Program" style="color: blue;"></a>A Balanced Exercise Program</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">Exercise programs that get the best results are made up of three main elements: aerobic conditioning, flexibility exercises, and strength training.</span><br />
<div style="margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Aerobic Conditioning</span></h4><div style="padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Aerobic exercise improves the health of your heart, lungs, and vascular system. It also helps you manage your weight because aerobic exercise burns more calories.</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">When you exercise aerobically, you move continuously to increase your heart rate. Your goal is to keep your heart rate elevated for a sustained period of time. How long you can exercise aerobically will depend on your fitness level. A general guideline is to work up to 20 to 30 minutes a day, three to four days a week.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Examples of aerobic exercise include walking, jogging, and biking. Many people prefer using machines, such as rowing machines, stair climbers, or treadmills.</span></div><div style="margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Flexibility Exercises</span></h4><div style="padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Stretching will help you improve your range of motion and how well you can move. Flexibility exercises also help lessen muscle tension and soreness, and reduce your risk for injury. Stretches for both your upper and lower body should be done at the end of every exercise session.</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">If improved flexibility is one of your fitness goals, specific activities, like yoga and tai chi, provide effective flexibility training.</span></div><div style="margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Strength Training</span></h4><div style="padding-top: 0px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Strength training is good for both your muscles and bones. Stronger bones and muscles reduce your risk for injury. In addition, increased muscle mass helps your body burn more calories when at rest. Being stronger also makes it easier to do everyday activities like carrying groceries or doing yard work.</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">The most common strength training methods are working with free weights and weight machines, or doing exercises that use your own body weight (push-ups, for example).</span></div><div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Establish a Reasonable Schedule" style="color: blue;"></a>Establish a Reasonable Schedule</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">Both new and experienced exercisers benefit from following a schedule. Set a weekly exercise schedule that includes days off. For example, you might exercise every other day, with 3 days off each week.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">Start with a program of moderate physical activity — perhaps 30 minutes a session. If 30 minutes is too much in the beginning, or you do not have enough time, break it up into shorter intervals. For instance, walk for 15 minutes in the morning and 15 minutes later in the day.</span><br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Stick With It" style="color: blue;"></a>Stick With It</span></div><span style="font-family: 'Trebuchet MS', sans-serif;">Focus on working toward your fitness goals gradually. Consider tracking your progress with a simple chart, perhaps listing the number of minutes you exercise each day. Your progress will start to show in the way you feel physically, and in how you feel emotionally.</span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;">There are many things you can do to help you stick with your exercise program.</span><br />
<ul><li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Keep exercise interesting by varying your routine. Do aerobic training on one day, then strength training the next. Mix it up with different activities such as walking, bicycle riding, an exercise class, or working in the garden.</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Do not stop exercising if you have muscle soreness. Some muscle soreness the day after you exercise is typical. This often occurs when you begin a fitness program, or when you increase the intensity of your exercise. Soreness will go away as you exercise regularly. If you experience severe pain and swelling, however, stop exercising and rest.</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Exercising with a friend often helps both people stay motivated and on track.</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Work towards an exercise goal, such as finishing a 5k run or participating in a group hiking trip.</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Choose a comfortable time of day to exercise. Do not exercise outdoors at mid-day when it is the warmest. Try not to work out too soon after a meal.</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Do not stop your fitness program — the benefits from exercise begin to diminish in 2 weeks and disappear in 2 to 8 months.</span></li>
<li style="padding-bottom: 10px;"><span style="font-family: 'Trebuchet MS', sans-serif;">Congratulate yourself for each accomplishment.</span></li>
</ul><div><span style="font-family: 'Trebuchet MS', sans-serif;">Thanks to the <a href="http://orthoinfo.aaos.org/topic.cfm?topic=A00416" target="_blank">AAOS </a>for the above.</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div><span style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-75386853295011787762012-01-19T14:51:00.000-05:002012-01-19T14:51:57.048-05:00A Study on Bilateral Knee Replacements<div style="background-color: white; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 1em; padding-left: 0px; padding-right: 1em; padding-top: 0px; text-align: left; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="color: #333333;"><span class="Apple-style-span" style="line-height: 1.5;">Patients frequently ask to have bilateral knee replacements when their pain in both knees becomes so severe that they cannot live with their pain and limitations. I usually advise against bilateral knee replacements based upon some previous studies which have indicated that the </span><span class="Apple-style-span" style="line-height: 24px;">complications</span><span class="Apple-style-span" style="line-height: 1.5;"> for these procedures in higher than if the knees were replaced one at a time or if they were staged three weeks apart. </span></span></span></div><div style="background-color: white; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 1em; padding-left: 0px; padding-right: 1em; padding-top: 0px; text-align: left; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="color: #333333;"><span class="Apple-style-span" style="line-height: 1.5;">Here is a study that addresses this issue. Read on...</span></span></span></div><div style="background-color: white; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 1.5; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 1em; padding-left: 0px; padding-right: 1em; padding-top: 0px; text-align: left; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">A new study by researchers at Hospital for Special Surgery has identified patients who are at a higher risk of morbidity and mortality when undergoing knee replacement surgery in both legs at the same time. The study found that patients who have a history of significant medical problems, especially congestive heart failure or pulmonary hypertension, are at increased risk for major complications.</span></div><div style="background-color: white; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 1.5; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 1em; padding-left: 0px; padding-right: 1em; padding-top: 0px; text-align: left; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">“What we sought to do for the first time with this study, was to provide evidence-based risk stratification for who should be considered at high risk for morbidity and mortality when undergoing bilateral knee replacement surgery,” said Stavros Memtsoudis, M.D., Ph.D., an anesthesiologist at Hospital for Special Surgery, who led the study. “This is an elective procedure, so in the end, the primary concern should be for patient safety.” The study appears online ahead of print in the journal <i>Anesthesia & Analgesia</i>.</span></div><div style="background-color: white; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 1.5; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 1em; padding-left: 0px; padding-right: 1em; padding-top: 0px; text-align: left; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Bilateral knee replacement surgery or total knee arthroplasty (TKA) has advantages over staged unilateral knee replacement surgery (which is considered the alternative to bilateral knee arthroplasty) in terms of decreasing the time that patients spend in a hospital, decreasing hospital costs, and allowing patients to return to work and an active life more quickly. <b>Studies have shown that bilateral knee replacements, however, are associated with greater morbidity and mortality than unilateral knee replacements.</b></span></div><div style="background-color: white; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 1.5; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 1em; padding-left: 0px; padding-right: 1em; padding-top: 0px; text-align: left; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">To find out which patients are more at risk, researchers at Hospital for Special Surgery turned to the Nationwide Inpatient Survey, sponsored by the Agency for Healthcare Research and Quality (AHRQ). This is the largest inpatient database available in the United States that includes information on patients of all ages. It collects data from about 20% of all hospitalizations in the U.S. This large cohort of patient information is unparalleled and allows for the appropriate study of relatively rare events such as morbidity and mortality surrounding surgery. The study investigators analyzed data between 1998 and 2007 and found that more than 200,000 bilateral TKAs were performed during this time frame. The incidence of major in-hospital complications and mortality was 9.5 percent. The researchers analyzed outcomes with respect to patient demographics including comorbidities such as heart problems, diabetes, liver dysfunction, cancer, and alcohol abuse. They used a multivariate analysis to determine independent risk factors for major morbidity and mortality.</span></div><div style="background-color: white; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 1.5; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 1em; padding-left: 0px; padding-right: 1em; padding-top: 0px; text-align: left; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Patients undergoing bilateral TKA were 5.5 times more likely to have adverse outcomes if they had congestive heart failure and four times more likely to have worse outcomes if they had pulmonary hypertension.</b> <b>Patients were almost twice as likely to have complications if they were older than 75 years of age compared to individuals below the age of 65 years. Men had a 50 percent greater risk of complications than women.</b></span></div><div style="background-color: white; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 1.5; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 1em; padding-left: 0px; padding-right: 1em; padding-top: 0px; text-align: left; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">“Age by itself will be a risk factor in any kind of surgery, so I am a little hesitant to say that patients who are over the age of 65 shouldn’t have bilateral knee replacement surgery, especially since a large number of knee replacement patients falls into that category. However, patients with extremes in age should be carefully evaluated before consideration for bilateral procedures.” said Dr. Memtsoudis. He added that the role of male gender is unclear, but could involve factors not accounted for in the analysis, such as hormonal differences.</span></div><div style="background-color: white; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 1.5; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 1em; padding-left: 0px; padding-right: 1em; padding-top: 0px; text-align: left; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">What should be clear from the study, however, is that patients with congestive heart failure and pulmonary hypertension as well as significant other comorbidities are not good candidates for this bilateral surgery. “During orthopedic surgery, bone particles and marrow enter the bloodstream and embolizes (lodges) in the pulmonary vasculature and other organs thus impacting on blood flow through the lung and other systems. While these events stress the heart, they rarely cause any clinically noticeable effects in otherwise healthy patients. However, people who have a history of heart failure are already at a disadvantage,” explained Dr. Memtsoudis. “When a patient has pre-existing pulmonary hypertension, this may also make it more difficult for their heart to pump blood against even more increased pulmonary pressures brought upon by the occlusion of small vessels in the lungs.”</span></div><div style="background-color: white; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 1.5; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 1em; padding-left: 0px; padding-right: 1em; padding-top: 0px; text-align: left; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The HSS researchers say national guidelines need to be developed regarding bilateral knee replacement surgery and are organizing a meeting for 2012 to discuss the development of such guidelines. “Clinicians need to adopt an approach when doing this surgery that reconciles the benefits of bilateral knee replacement surgery and concerns for safety,” said Dr. Memtsoudis. “In order to do that, they will need to use evidence-based criteria of who should and who shouldn’t be considered an appropriate candidate for bilateral knee replacement. What we are providing with this study is the first step towards an evidence-based approach to risk stratifying patients.”</span></div><div style="background-color: white; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 1.5; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 1em; padding-left: 0px; padding-right: 1em; padding-top: 0px; text-align: left; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Almost 600,000 knee replacements are performed each year in the United States. These numbers are expected to rise as baby boomers, who are often reluctant to give up their active lifestyle, age.</span></div><div style="background-color: white; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 1.5; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 1em; padding-left: 0px; padding-right: 1em; padding-top: 0px; text-align: left; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;">The study was funded by the Department of Anesthesiology at HSS, the AHRQ Center for Education and Research in Therapeutics, and the National Institutes of Health.<br />
Other Hospital for Special Surgery researchers involved with the study are Yan M, Ph.D., Ya-Lin Chiu, M.S., Lazaros Poultsides, M.D., Ph.D., Alejandro Gonzalez Della Valle, M.D., and Madhu Mazumdar, Ph.D.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">My opinion is that the risk of bilateral simultaneous knee replacements is high enough to advise against this. I generally advocate that patients wanting both knees replaced stage them 3 weeks apart. This reduces the risk of cardiac and pulmonary complications while allowing them to recover from both knees over a relatively shorter time frame.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;"><br />
</span></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-45785266575397736562011-10-19T14:10:00.000-04:002011-10-19T14:10:26.711-04:00<span class="Apple-style-span" style="background-color: white; line-height: 16px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"></span></span><br />
<div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><strong>Herbal Supplements May Cause Dangerous Drug Interactions in Orthopaedic Surgery Patients</strong><br style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /><em>Discontinuing use prior to surgery can help avoid adverse events</em></span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><em><br />
</em></span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Complementary and alternative medical (CAM) treatments such as herbal supplements have become increasingly popular in the United States, especially among older patients and those with chronic pain. However, many of these products can have serious and potentially harmful side effects when combined with medications prescribed during and after surgery, according to a review article in the <i><a href="http://www.jaaos.org/" style="color: #003399;" target="_blank">Journal of the American Academy of Orthopaedic Surgeons</a></i> (JAAOS).</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">About 20 percent of prescription users also take an herbal supplement, and those rates are higher — studies suggest between 35 and 70 percent — among orthopaedic patients who are candidates for surgery.</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Herbal remedies are classified as dietary supplements, meaning they are exempt from the safety and efficacy regulations that the U.S. Food and Drug Administration (FDA) requires for prescription and over-the-counter medications. As a result, individual herbal remedies have not been thoroughly evaluated in large clinical trials, and little information is available on the interactions between drugs and herbs.</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In addition, many herbal products are marketed as “natural” or “homeopathic,” which may lead consumers to assume the products are safe, even when taken with prescription medicines. Herbal supplements can have a negative impact on patients both before and following surgery, and may interact with conventional medicines used to manage chronic conditions.</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Traditional physician-patient communications, like intake interviews, often do not include the subject of alternative medical products. As a result, patients may fail to report that they are using them and continue to take them along with any prescribed medicines and before surgery, thinking the herbal products pose no risk.</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Many of the most popular herbal supplements used today can have serious side effects when combined with prescription medicines. For example:</b></span></div><ul style="margin-bottom: 0.7em; margin-left: 1.5em; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Feverfew (used for migraine prevention), ginger, cranberry, St. John’s Wort and ginseng can interact with the anti-clotting drug warfarin;</span></li>
<li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Feverfew, ginger, and gingko can interact with aspirin;</span></li>
<li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Garlic can interfere with anti-clotting medications and the immunosuppressant drug cyclosporine (prevents transplant rejection);</span></li>
<li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Valerian (used as a sedative) can intensify anesthetics; and</span></li>
<li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">St. John’s Wort can interact with immunosuppressive drugs and potentially lead to transplant rejection.</span></li>
</ul><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Herbal products marketed for osteoarthritis also can pose serious risks when combined with prescription medications. For example:</b></span></div><ul style="margin-bottom: 0.7em; margin-left: 1.5em; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Glucosamine, chondroitin and flavocoxid can affect clotting agents;</span></li>
<li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Black cohosh can interact with the cancer drug tamoxifen; and</span></li>
<li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Cat’s claw can interact with clotting agents, blood pressure medications and cyclosporine.</span></li>
</ul><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Most surgery-related side effects can be avoided by stopping the CAM product at least one to two weeks prior to surgery and during the postoperative period while prescription medications such as blood thinners or antibiotics are being used. The problem arises when physicians do not know that a patient is using a CAM product.</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">One of the main reasons that patients do not disclose the use of a CAM product is that they may not believe it is important information to convey to the physician because they feel they are safe to use and all-natural. Patients may also decide not to report CAM product use if they are worried their physician may be prejudiced against the supplement’s use, or believe their physician will not have an understanding of the supplement.</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">To help ensure physicians are aware of the products their patients may be using, the patient history taken in the office includes CAM product-use questions on health/medical assessment forms to encourage patient disclosure.</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Physician-patient communication often does not include the use of CAM therapies, which results in underreporting of their use. To help avoid potential side effects, orthopaedists should develop questionnaires that can be used prior to surgery to help determine if their patients are using CAM products. Alternatively, patients should also report usage of any herbal products or other supplements they may be taking to all their physicians.</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">From the <a href="http://www6.aaos.org/news/pemr/releases/release.cfm?releasenum=1024">AAOS</a></span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="margin-bottom: 0.7em; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-83365240088645827692011-10-19T14:01:00.000-04:002011-10-19T14:01:53.089-04:00Rotator Cuff Tears: Frequently Asked Questions<div><span class="Apple-style-span" style="color: #006666; font-family: 'Trebuchet MS', sans-serif; font-weight: bold;"><span class="Apple-style-span" style="color: black; font-weight: normal;">From the AAOS.org</span></span></div><span class="Apple-style-span" style="color: #006666; font-family: 'Trebuchet MS', sans-serif; font-weight: bold;"></span><br />
<div><span class="Apple-style-span" style="color: #006666; font-family: 'Trebuchet MS', sans-serif; font-weight: bold;"><span class="Apple-style-span" style="color: #006666; font-family: 'Trebuchet MS', sans-serif; font-weight: bold;"><br />
</span></span></div><span class="Apple-style-span" style="color: #006666; font-family: 'Trebuchet MS', sans-serif; font-weight: bold;">What is the rotator cuff and what does it do?</span><br />
<div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The rotator cuff is a large tendon comprised of four muscles which combine to form a "cuff" over the upper end of the arm, the head of the humerus. The four muscles—supraspinatus, infraspinatus, subscapularis and teres minor—originate from the "wing bone," the scapula, and together form a single tendon unit that inserts on the greater tuberosity of the humerus.<br />
<br />
The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint.</span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"></span><br />
<div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></span></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">A rotator cuff tear may result from an acute injury such as a fall or may be caused by chronic wear and tear with degeneration of the tendon. Impingement of the front of the scapula, the acromion, on the tendon is believed to be a major cause of cuff tears in individuals older than 40 years.</span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><a href="http://www.blogger.com/post-edit.g?blogID=5036891362124971703&postID=8336524008864582769" name="What causes a rotator cuff tear and how would I know if I have one?" style="color: blue;"></a>What causes a rotator cuff tear and how would I know if I have one?</div>Typically, you will feel pain in the front of your shoulder that radiates down the side of your arm. It may be present with overhead activities such as lifting or reaching. You may feel pain when you try to sleep on the affected side. You may note weakness of your arm and difficulty with routine activities such as combing your hair or reaching behind your back.</span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
If the tear occurs with injury you may experience acute pain, a snapping sensation, and immediate weakness of the arm.<br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><a href="http://www.blogger.com/post-edit.g?blogID=5036891362124971703&postID=8336524008864582769" name="If I have a painful rotator cuff and keep using it, will this cause further damage?" style="color: blue;"></a>If I have a painful rotator cuff and keep using it, will this cause further damage?</div>A rotator cuff tear can extend or get larger over time. This can occur with repetitive use or a re-injury. It is common for patients with known rotator cuff disease to have acute pain and weakness following a minor injury. This likely represents extension of an existing tear.</span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
If you know you have a rotator cuff tear, then worsening pain and decreasing strength may mean the tear is getting larger.<br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><a href="http://www.blogger.com/post-edit.g?blogID=5036891362124971703&postID=8336524008864582769" name="When should I see a doctor for a rotator cuff tear?" style="color: blue;"></a>When should I see a doctor for a rotator cuff tear?</div>If you have injured your shoulder or have chronic shoulder and arm pain, it is best to see your orthopedic surgeon. He or she can then make a diagnosis and begin treatment. The doctor may recommend a diagnostic study such as MRI (magnetic resonance imaging) to confirm the diagnosis.</span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
Early diagnosis and treatment of a rotator cuff tear may prevent symptoms such as loss of strength and loss of motion from setting in.<br />
If your primary physician has already made the diagnosis, an orthopaedic surgeon can review both surgical and nonsurgical options and start treatment.<br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><a href="http://www.blogger.com/post-edit.g?blogID=5036891362124971703&postID=8336524008864582769" name="Can a rotator cuff tear be healed or strengthened without surgery?" style="color: blue;"></a>Can a rotator cuff tear be healed or strengthened without surgery?</div>Many rotator cuff tears can initially be treated nonsurgically. Anti-inflammatory medication, steroid injections, and physical therapy may all be of benefit in treating symptoms of a cuff tear. The goals of treatment are to relieve pain and restore strength to the involved shoulder.</span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
Even though tears cannot heal on their own, satisfactory function can sometimes be achieved without surgery. Patients must understand that an unrepaired rotator cuff tear will never heal. These tears get worse over time. Small tears progress slowly and larger tears will worsen more quickly over time. Eventually the tendon may be so badly torn and retracted that it cannot be repaired at all. This can be a major functional impairment in a younger more active patient, and a source of pain and inconvenience for older patients with fewer physical demands</span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
If, however, you are active and use your arm for overhead work or sports, then surgery is most often recommended because many tears will not heal without surgery.<br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><a href="http://www.blogger.com/post-edit.g?blogID=5036891362124971703&postID=8336524008864582769" name="At what point does a rotator cuff tear require surgery to fix it?" style="color: blue;"></a>At what point does a rotator cuff tear require surgery to fix it?</div>Surgery is recommended if you have persistent pain or weakness in your shoulder that does not improve with nonsurgical treatment. Frequently, patients who require surgery will report pain at night and difficulty using the arm for lifting and reaching. Many will report ongoing symptoms despite several months of medication and limited use of the arm.<br />
Surgery is also indicated in active individuals who use the arm for overhead work or sports. Pitchers, swimmers, and tennis players are common examples.<br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><a href="http://www.blogger.com/post-edit.g?blogID=5036891362124971703&postID=8336524008864582769" name="What options are available for surgical repair?" style="color: blue;"></a>What options are available for surgical repair?</div>The type of repair performed is based on the findings at surgery. A partial tear may require only a trimming or smoothing procedure called a débridement. Whether a partial tear requires a repair or a </span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">débridement will depend on the degree or the tear. </span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">A full-thickness tear within the substance of the tendon can be repaired side to side. If the tendon is torn from its insertion on the humerus, it is repaired directly to bone.</span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> Three techniques are used for rotator cuff repair: traditional open repair, mini-open repair, and arthroscopic repair.</span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
Dr Mazzara can recommend which technique is best for you. In all circumstances, the tendon heals to the bone in 6 weeks. In my opinion, arthroscopic repair may not be best for every tendon tear, especially those that<br />
<div class="header1" style="border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><a href="http://www.blogger.com/post-edit.g?blogID=5036891362124971703&postID=8336524008864582769" name="How important is rehabilitation in the treatment of a rotator cuff tear?" style="color: blue;"></a>How important is rehabilitation in the treatment of a rotator cuff tear?</div>Rehabilitation plays a critical role in both the nonsurgical and surgical treatment of a rotator cuff tear.</span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
When a tear occurs, there is frequently atrophy of the muscles around the arm and loss of motion of the shoulder. An exercise or physical therapy program is necessary to regain strength and improve function in the shoulder.</span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
Even though surgery repairs the defect in the tendon, the muscles around the arm remain weak, and a strong effort at rehabilitation is necessary for the procedure to succeed. Complete rehabilitation after surgery may take several months.<br />
Dr Mazzara can prescribe an appropriate program based on your needs and the findings at surgery.<br />
<br />
<br />
Thanks,</span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD<br />
<br />
</span></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-36280947614346005102011-05-18T09:37:00.000-04:002011-05-18T09:37:22.141-04:00Introduction to Chondroprotection<div class="expiredWrapper"><span class="expiredMessage"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"></span></span><br />
<div style="font-weight: bold;"></div></div><table class="contentpaneopen"><tbody>
<tr><td valign="top"><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-tcWY1zKbi3U/TdPLgjLlklI/AAAAAAAABEE/Fc7OnUkIEQM/s1600/images+%25282%2529.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://3.bp.blogspot.com/-tcWY1zKbi3U/TdPLgjLlklI/AAAAAAAABEE/Fc7OnUkIEQM/s1600/images+%25282%2529.jpg" /></a></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Not a day goes by when I am not asked about what patients can do to alter the arthritis changes that affect their joints resulting in pain and impairment in their daily lives. Below is an article from an online <a href="http://www.ortho.hyperguides.com/index.php?option=com_content&view=article&id=1899">reference </a>that explores the issue of protecting what cartilage remains in the arthritis joint. <br />
<br />
<span id="goog_561014997"></span><span id="goog_561014998"></span><br />
<br />
<strong>Introduction</strong><br />
Osteoarthritis is a common, chronic, and debilitating disease. There are few effective treatments, with joint replacement a primary exception. A joint replacement, however, is costly to the healthcare system, and the procedure carries risk. The remaining therapies are moderately effective at best, and none have been clearly demonstrated to alter the natural history of the disease. For this reason a large focus of drug development in osteoarthritis is identification of a disease modifying osteoarthritis drug (DMOAD) that is safe and provides some structural modification. Several therapeutic targets have been identified, with the most frequent target involving cartilage. The term chondroprotection is now used to categorize these agents.<br />
<br />
We will review briefly the potential molecular targets, the agents thus far developed, and the evidence for their use.<br />
<br />
<strong>Potential Targets<br />
</strong>There are a number of molecular targets for DMOAD development. These include inhibiting molecules that break down cartilage, such as Interleukin-1(IL-1), aggrecanases, and matrix metalloproteinases (MMPs); components of healthy cartilage and synovial fluid, such as glucosamine, chondroitin sulfate, and hyaluronan; and promoters of cartilage growth and repair (TGFβ, such as bone morphogenic protein.)<br />
<br />
<strong>Doxycycline and Diacerein</strong><br />
Tetracyclines appear to be inhibitors of several MMPs, including collagenase and gelatinase,<sup> </sup>which are known to be upregulated in arthritic cartilage. In animal models and in some human trials, doxycycline appeared to have a modest benefit. In one human study, the rate of joint space narrowing in the group receiving doxycycline was 33% less, although there was no effect on pain.<sup><br />
</sup>Diacerein, available only in Europe, has an active metabolite that inhibits IL-1β, a known component of immune response in osteoarthritis. A recent systematic review showed a modest pain benefit in osteoarthritis.<span class="Apple-style-span" style="font-size: x-small;"> </span>The data on structural benefits, however, are weak.<br />
<br />
<strong>Hyaluronan</strong><br />
Hyaluronan is an integral component of healthy cartilage and synovial fluid in joints. It serves numerous functions within the joint and has been identified as an important molecule in the pathogenesis of osteoarthritis. Synthetic hyaluronan (what I often refer to as "joint lubricants" or viscosupplements) has been available as a therapeutic agent with the potential to improve pain, joint function, and joint structure. A recent meta-analysis comparing hyaluronan in intra-articular corticosteroids showed a relative pain benefit with hyaluronan; another comparing hyaluronan to placebo confirmed a modest but statistically significant benefit for hyaluronan. Early data suggest that there may be some disease-modifying effects as well, but larger studies are needed.<br />
<br />
<strong>Vitamins<br />
</strong>Nutritional micronutrients are known to be important for cartilage health. Numerous micronutrients have been proffered as therapies, including selenium, beta carotene, and vitamins C, D, E, and K.<span class="Apple-style-span" style="font-size: x-small;"> </span>The data supporting their use are limited, and toxicity at high doses is a concern for several, including vitamin D.<br />
<br />
<strong>Herbals<br />
</strong>Several herbal remedies for knee osteoarthritis have been advocated, including avocado/soybean unsaponifiables (ASU) and rose hip extracts. ASU has a variety of potential effects, including promotion of immunomodulation and cartilage synthesis. It has been shown to have modest pain benefit compared with placebo in knee osteoarthritis. Rose hip is thought to have antioxidant properties due to high vitamin C and lycopene content, and it has been shown to improve pain in knee osteoarthritis in a meta-analysis of several small studies.<sup> </sup>Data on structural modification are lacking for both of these agents.<br />
<br />
<strong>Glucosamine and Chondroitin<br />
</strong>Glucosamine and chondroitin are important components of cartilage. Increasing the level of these substrates could, theoretically, aid in cartilage repair or slow cartilage destruction. Their use as osteoarthritis treatment has received a great deal of attention and controversy. Although several studies have shown a symptomatic benefit, a large nonindustry-sponsored study demonstrated no benefit for knee osteoarthritis.<span class="Apple-style-span" style="font-size: x-small;"> </span> Meta-analyses support a modest pain benefit, but the results are heterogeneous. Evidence that these agents modify structure shows a modest, but statistically significant benefit,<sup> </sup>but the results were heterogeneous, making interpretation difficult.<br />
<br />
<strong>Clinical Guidelines<br />
</strong>Clinical guidelines vary for each of the agents currently available. Several support the use of hyaluronan, glucosamine, and chondroitin,<sup> </sup>while the American Academy of Orthopaedic Surgeons does not recommend use of either. <sup> </sup>The remaining agents have not been mentioned in clinical guidelines due to insufficient data. The clinician must balance the relative safety of these agents, the desires of the patient, and the emerging evidence when recommending them.<br />
<br />
<strong>Summary</strong><br />
Development of a DMOAD that demonstrates halting or slowing of structural damage in osteoarthritis is a major focus of research efforts. Some have been found to improve pain in osteoarthritis, but the data for structural modification are relatively weak. More evidence will be required. Additionally, we must consider whether to accept structural benefit without a pain benefit when designing new studies. Lastly, identification of DMARDs likely requires a more sensitive biomarker than the X-rays used in most of these studies.<br />
<br />
<strong><a href="http://www.ortho.hyperguides.com/index.php?option=com_content&view=article&id=1899"><span class="Apple-style-span" style="font-size: xx-small;">Reference</span></a></strong></span></td></tr>
</tbody></table><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="-webkit-border-horizontal-spacing: 2px; -webkit-border-vertical-spacing: 2px;">A very nice summary.</span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="-webkit-border-horizontal-spacing: 2px; -webkit-border-vertical-spacing: 2px;"><br />
</span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="-webkit-border-horizontal-spacing: 2px; -webkit-border-vertical-spacing: 2px;">Thanks,</span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="-webkit-border-horizontal-spacing: 2px; -webkit-border-vertical-spacing: 2px;"><br />
</span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="-webkit-border-horizontal-spacing: 2px; -webkit-border-vertical-spacing: 2px;">JTM, MD</span></span>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-72922257160539880282011-05-15T19:21:00.000-04:002011-05-15T19:21:52.806-04:00What causes tendon wear and tear called tendinopathy?<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">I am frequently asked about the cause of those wear and tear changes we see in the tendons of the rotator cuff and elsewhere in the body. In general, I explain it is a result of those age related changes that we all experience in life. A study below explores that topic further and may shed some light on why some patients who may not be active develop tendon problems. It is translated from orthopedics to English below.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 16px;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 16px;">Conventional thinking says that tendinopathy—defined as chronic tendon degeneration—is due to tendon overload, leading to microscopic collagen fiber failure and a failed healing response</span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 16px;">. It also says that inflammation is not part of the pathologic process, because inflammatory cells are not seen in biopsies obtained at the time of surgery in patients with tendinosis.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"></div><table style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; border-collapse: collapse; line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; width: 442px;"><tbody>
<tr><td style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.2em; padding-left: 0.4em; padding-right: 0.4em; padding-top: 0.2em; vertical-align: top;" valign="top" width="734"><div style="margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><img alt="SSM - Tendinopathy.gif" border="1" height="180" src="http://www.aaos.org/news/aaosnow/may11/clinical3-1.gif" style="border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; clear: both;" width="250" /></span></div></td></tr>
<tr><td style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0.2em; padding-left: 0.4em; padding-right: 0.4em; padding-top: 0.2em; vertical-align: top;" valign="top" width="734"><div style="margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><i><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Fig. 1</b> Histologic appearance of tendinosis tissue shows a characteristic pattern of fibroblasts and vascular, atypical, granulation-like tissue. Courtesy of Scott A. Rodeo, MD</span></i></div></td></tr>
</tbody></table><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">But according to recent studies tendinopathy may be due to mechanical understimulation of tendon cells, rather than tendon overload, and that abnormal differentiation of tendon stem cells may play a role in the development of the condition.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In addition, he noted, there may be an important interaction among load, inflammatory mediator expression, and matrix metalloproteinase (MMP) expression at the microscopic level.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br />
</b></span></div><div style="margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><div style="line-height: 16px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Tendon overload vs. “underload”</b></span></div><div style="line-height: 16px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></b>According recent studies have demonstrated that stress deprivation leads to increases of collagenase (which breaks down collagen in tendons) expression and a loss of tendon cells.</span></div><div style="line-height: 16px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 16px;">In addition, he noted, there may be an important interaction among stress on the tendon inflammation, and matrix metalloproteinase (MMP) expression at the microscopic level. MMP breaks down tendon tissue.</span></span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"></span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">This collagenase production may weaken the tendon and put more of the extracellular matrix at risk for further damage during subsequent loading.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">More than a decade of research has shown that microscopic collagen fiber failure may play an important role in the development of tendinopathy.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">When microscopic collagen fiber failure occurs, cells in the injured area are exposed to less load; they are deprived of stress. This leads to upregulation of interleukin-1 beta (IL-1β), which is an inflammatory mediator, as well as upregulation of MMPs. The end result is decreased structural and mechanical properties.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Stem cells</b></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></b>Stem cells may also play a role in the development of tendinopathy. Tendon stem cells can differentiate into tenocytes, which lead to tendon repair, or into osteocytes or adipocytes.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Researchers have found that treating tendon stem cell cultures with prostaglandin E2 (PGE2) induces both adipogenesis and osteogenesis. As a result, the number of tenocytes is reduced and fatty and calcified tissues are produced, as seen in tendinopathy.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">An analysis of the effect of mechanical load on tendon stem cells found that when tendon stem cells were stretched, they could continue to differentiate into tenocytes with 4 percent strain. At an 8 percent strain, however, some of the cells differentiated into adipogenic, chondrogenic, and osteogenic lineages. “So, mechanical load clearly plays a role in these pathways,” he concluded.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Inflammatory mediators</b></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></b>The expression of inflammatory mediators may occur in the early stages of tissue injury. MMPs play an important role in tissue degradation and matrix remodeling and that inflammatory mediator expression can increase MMP activity.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Imbalances between MMPs and their inhibitors have been implicated in the underlying origin of tendinopathy.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Researchers conducted a study in which they biopsied rotator cuff synovium and bursa at the time of rotator cuff repair. They found increased expression of MMPs and inflammatory mediators. Increased synovial inflammation and tissue degradation correlated with cuff tear size.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Implications for treatment</b></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></b></span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Eccentric exercise may work via mechanical stimulation, leading to modulation of inflammatory mediators and a shift in the balance of MMPs and catabolic and anabolic gene expression.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">MMP inhibitors have the potential to prevent ongoing tendon degeneration.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Some studies have shown that MMP inhibitors can prevent the matrix degeneration that occurs with stress deprivation in rat tail tendon. In addition, MMP inhibitors prevented loss of material properties associated with stress deprivation.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Therefore, new agents that block either inflammatory mediators or MMPs may be effective in treatment of tendinosis.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Bottom line</span></b></div><ul compact="" style="line-height: 16px; margin-bottom: 0.7em; margin-left: 1.5em; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" type="disc"><li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Recent studies have found that mechanical understimulation of tendon cells, rather than tendon overload, may cause tendinopathy and that abnormal differentiation of tendon stem cells may play a role in its development.</span></li>
<li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Research also indicates important interactions occur among load, inflammatory mediator expression, and MMP expression at the microscopic level.</span></li>
<li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Future studies involving the role of mechanical load may suggest ways to modulate the loading environment to stimulate tissue repair.</span></li>
<li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">MMP inhibitors may have the potential to prevent ongoing tendon degeneration.</span></li>
</ul><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Additional resources</span></b></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><u><a href="http://www.aaos.org/news/aaosnow/sep10/clinical2.asp" style="color: #003399;">Treating tendinopathy with PRP</a><a href="http://www.aaos.org/news/aaosnow/oct10/clinical1.asp" style="color: #003399;"><br style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" />Tendinopathy treatment tips</a></u><a href="http://www.blogger.com/post-edit.g?blogID=5036891362124971703&postID=7292225716053988028" name="P61_6400" style="color: #003399;"></a></span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">AAOS <em>Now</em><br style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" />May 2011 Issue</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><a href="http://www.aaos.org/news/aaosnow/may11/clinical3.asp"><span class="Apple-style-span" style="font-size: xx-small;">Reference</span></a></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-68767853304329543282011-05-03T07:50:00.000-04:002011-05-03T07:50:26.712-04:00Knuckle Cracking and Hand Osteoarthritis<div style="font-family: "Trebuchet MS",sans-serif;"> </div><div id="bodypadding" style="font-family: "Trebuchet MS",sans-serif;"><div id="contentbody"><div id="legaltextsection"><div class="inactive" id="authordisclosures"><div class="layerbg2"><div class="scrolllayer"> <span style="font-size: small;"><strong>I am frequently asked by patients if knuckle cracking will lead to arthritis of the hand. It is a question asked by mothers whose sons (usually) have the annoying habit of cracking their knuckles. I have always indicated that there is no connection between the cracking of knuckles and hand arthritis but now there is a study that has proven that. Sorry Mom.</strong></span><span style="font-size: small;"> </span></div></div></div><h2><span style="font-size: xx-small;">From <a href="http://www.medscape.com/index/list_4832_0">Journal of the American Board of Family Medicine</a></span> </h2><span style="font-size: small;">Background: Previous studies have not shown a correlation between knuckle cracking (KC) and hand osteoarthritis (OA). However, one study showed an inverse correlation between KC and metacarpophalangeal joint OA.</span><br />
<br />
<span style="font-size: small;"></span><br />
<span style="font-size: small;">The authors</span><span style="font-size: small;"> conducted a retrospective case-control study among persons aged 50 to 89 years who received a radiograph of the right hand during the last 5 years. Patients had radiographically proven hand osteoarthritis (wear and tear arthritis) OA, and controls did not. Participants indicated frequency, duration, and details of their knuckle cracking behavior and known risk factors for hand OA.</span><br />
<span style="font-size: small;"><br />
Results:</span> <span style="font-size: small;"> The prevalence of knuckle cracking among 215 respondents (135 patients, 80 controls) was 20%. When examined in aggregate, the prevalence of OA in any joint was similar among those who crack knuckles (18.1%) and those who do not (21.5%; <em>P</em> = .548). When examined by joint type, knuckle cracking was not a risk for osteoarthritis in that joint. Total past duration (in years) and volume (daily frequency × years) of knuckle cracking of each joint type also was not significantly correlated with OA at the respective joint.</span><br />
<span style="font-size: small;"><br />
Conclusions:</span> <span style="font-size: small;"> A history of habitual KC—including the total duration and total cumulative exposure—does not seem to be a risk factor for hand OA.</span><br />
<h4><span style="font-size: small;">Introduction</span></h4><span style="font-size: small;">Knuckle cracking (KC) is a behavior that involves manipulation of the finger joints that results in an audible crack, and it is often done habitually. Prevalence estimates vary between 25% and 54%, depending on the population studied.</span><br />
The behavior can become habitual because of immediate joint tension release and increased joint range of motion.<br />
<br />
<br />
<span style="font-size: small;">During an attempt to crack a knuckle, the joint is manipulated by axial distraction, hyperflexion, hyperextension, or lateral deviation. This lengthens part or all of the joint space and greatly decreases intra-articular pressure, causing gases that have dissolved in the synovial fluid to form microscopic bubbles, which coalesce. When the joint space reaches its maximum distraction (up to 3 times its resting joint space distance), joint fluid rushes into the areas of negative pressure. The larger bubbles suddenly collapse into numerous microscopic bubbles, leading to the characteristic cracking sound. The maneuver leaves the joint space wider than it had been and synovial fluid more widely distributed. The stretching of joint ligaments required to produce the widened joint space also leaves the joint with greater range of motion. It typically takes at least 15 minutes for the joint to be able to be cracked again because of the time required for the microscopic bubbles to fully dissolve into solution and for the joint space to retract back to its resting position.</span><br />
<span style="font-size: small;"> </span> <br />
<span style="font-size: small;">Common urban legend suggests that knuckle cracking will lead to arthritis of the hand joints. Adverse effects of knuckle cracking have been cited but are not well supported in the medical literature. Case reports of acute joint damage from unusually vigorous and deviant knuckle cracking attempts are rare. </span><br />
<br />
<span style="font-size: small;"><sup> </sup></span> <br />
<span style="font-size: small;">The amount of force required to crack a knuckle has been shown <em>in vitro</em> studies to exceed the energy threshold that can lead to articular cartilage damage.</span><br />
<br />
<span style="font-size: small;"> Based on these facts, it is logical to theorize that habitual knuckle cracking may lead to gradual thinning of articular cartilage and eventual clinical osteoarthritis (OA). However, this claim remains unsubstantiated in the medical literature.</span> The cavitation effect of intra-articular bubble formation and collapse is also mechanically similar to cavitation of ship propellers, a process that has been shown to produce wear on the propeller surfaces.<br />
<br />
<span style="font-size: small;">A MEDLINE search using keywords "joint cracking" and "knuckle cracking" revealed 2 studies that addressed the incidence of OA in knuckle crackers. The first looked at 300 randomly selected persons older than age 45 (mean age, 63 years). Participants were assessed by a questionnaire and a physical examination of the hands. Those who cracked knuckles were more likely to have hand swelling and reduced grip strength, but the prevalence of hand OA was 16% among those who cracked knuckles and those who did not. The investigators did not specify which joints were cracked nor which joints were affected with OA.</span><br />
<br />
<span style="font-size: small;">Another study involved examination of the hand radiographs of 28 nursing home residents (average age, 78 years). Participants were asked to recall if they currently or previously cracked knuckles, but investigators did not specify which joints. In this study, knuckle cracking of the MCP (first knuckle of the fingers) joint was found to be negatively correlated with OA. The prevalence of KC in the 6 persons with OA of the MCP joint was 17%, whereas the prevalence of KC in the group without OA of the MCP joint was 64%. This suggests that KC may be associated with a lower prevalence of OA at the MCP joint.</span><br />
<span style="font-size: small;"> </span> <br />
<span style="font-size: small;">Though somewhat useful, neither of these studies specified which joints participants cracked. Neither quantified the duration or frequency of KC, both of which could have correlations with the presence or absence of OA. Duration and frequency may be relevant because, based on the mechanical logic above, the more times that the maneuver is performed, the more the risk of mechanical wear on affected surfaces would, theoretically, increase.</span><br />
<br />
<span style="font-size: small;">OA of the hand increases in prevalence and severity with age.The prevalence of symptomatic hand OA has been reported to be 22% in persons age 71 to 100 years among the general population. Other risk factors include prior joint trauma, family history of hand OA, and history of heavy labor involving the hands. Those with hand OA have reduced maximal grip strength, more difficulty writing and handling small objects, and more difficulty carrying objects. Given this burden of suffering from hand OA and the lack of curative or disease-modifying treatments, factors that potentially protect against OA warrant further investigation. One such factor is knuckle cracking.</span><br />
<br />
<span style="font-size: small;">This study represents the most comprehensive evaluation to date of habitual KC and any association with hand OA. Our findings support the conclusions of 2 previous studies. It confirms that the presence of knuckle cracking is not associated with hand osteoarthritis. This is the first study to correlate the duration and the total volume of previous knuckle cracking with OA, in addition to the presence or absence of knuckle cracking. Participants described how frequently each day they crack each type of knuckle and for how many years they have been doing it. First, our results indicated that the duration of KC has no correlation to the presence of OA in the DIP, PIP, and MCP joints. </span><br />
<br />
<span style="font-size: small;">They also calculated "crack-years," which roughly quantified the total amount of exposure to this behavior. This allowed investigation of a possible "dose–response" relationship between the mechanical effects of knuckle cracking and OA. Again, when looking at knuckle cracking of each joint type, the authors found no significant correlation of "crack-years" with OA in the respective joint.</span><br />
<br />
<span style="font-size: small;">What we do not know yet are all the reasons why people crack their knuckles and the effect this has on their joints in the long term. Though some people may start knuckle cracking because of joint symptoms, patients with OA in our study started knuckle cracking long before the onset of OA symptoms. Some people may crack knuckles because of the sense of relief it can bring, some because of habit, and some from both. People may stop knuckle cracking when hand symptoms appear either because of fear of what knuckle cracking might do to their joints or because knuckle cracking becomes too uncomfortable. </span><br />
<span style="font-size: small;"><br />
</span><br />
<span style="font-size: small;">What we can conclude, however, is that, in these cohorts of persons aged 50 to 89 years, a history of habitual KC—including the total duration and total cumulative exposure to KC—does not seem to be a risk factor for hand OA. </span><br />
<br />
<span style="font-size: small;"></span><br />
<span style="font-size: small;"><span style="font-size: xx-small;"><a href="http://www.medscape.com/viewarticle/739188?sssdmh=dm1.683790&src=journalnl">Reference: Translated from Orthopedics to English for better patient understanding by JTM</a></span></span><br />
<br />
<span style="font-size: small;"><span style="font-size: xx-small;"><span style="font-size: small;">Thanks</span>,</span></span><br />
<br />
<span style="font-size: small;"><span style="font-size: small;">JTM, MD</span><br />
</span><br />
</div></div><div id="bottomspacer"><span style="font-size: small;"> </span></div></div><span style="font-size: small;"><img alt="" border="0" src="http://bi.medscape.com/pi/1x1/pv/www-1x1.gif?1304421835805" style="font-family: "Trebuchet MS",sans-serif;" /></span>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-7403511471012359722011-04-21T17:05:00.000-04:002011-04-21T17:05:38.604-04:00PRP does not improve rotator cuff healing<div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Patients commonly ask about platelet rich plasma for treatment for their condition. It has been studied in the rotator cuff, elbow tendons as well as the Achilles tendon. Here is some information from AAOS.org on PRP for the rotator cuff. </span></div><h1 style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"></span></h1><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><b>Two separate randomized trials show no benefit to using PRP fibrin matrix</b></span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Improving healing after a rotator cuff tendon repair is an ongoing problem for orthopaedic surgeons world wide. In two separate studies—one European and one American—presented at the AAOS 2011 Annual Meeting, researchers found that one of the latest tools for healing injuries, platelet-rich plasma (PRP), does not make a big difference.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">The results of “Platelet-rich plasma augmentation for arthroscopic rotator cuff repair: A randomized controlled trial,” were presented as a podium presentation during the AAOS Annual Meeting. Using PRP with a fibrin matrix (PRFM) provided no superior clinical or structural outcome when compared with the more traditionally, technically less demanding, and economically more advantageous technique of nonaugmented suture anchor repair.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">The study included 88 patients who were randomized to two groups—one that received PRFM (Fig. 1) and one that did not. All patients had a repairable full-thickness tear of the rotator cuff and associated pathology of the long head of the biceps, but no episodes of shoulder instability or radiographic evidence of glenoid or greater or lesser tuberosity fracture.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"> </div><table style="font-family: "Trebuchet MS",sans-serif;"><tbody>
<tr> <td valign="top" width="638"><span style="font-size: small;"><img alt="P_Fig 1A.gif" border="1" height="389" src="http://www.aaos.org/news/aaosnow/apr11/clinical4-1.gif" width="238" /></span><br />
</td></tr>
<tr> <td valign="top" width="638"><span style="font-size: small;"><i><b>Fig. 1 A, A</b> platelet-rich fibrin matrix is a flat, circular membrane of autologous suturable fibrin that must be used within 30 minutes. <b>B, </b>An intraoperative arthroscopic image of the platelet-rich fibrin matrix interposed between rotator cuff and bone. Courtesy of Roberto Castricini, MD</i></span><br />
<br />
</td></tr>
</tbody></table><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">The groups were comparable in initial demographics and preoperative measures such as range of movement, strength, and pain (based on Constant scores). Sixteen months after surgery, using the same measures, researchers found no difference in scores between the two groups (<a href="http://www.aaos.org/news/aaosnow/apr11/clinical4_t1.pdf"><u>Table 1</u></a>). Although magnetic resonance imaging (MRI) found more evidence of rerupture in the group that did not receive the PRFM, further treatment was not necessary because the patients were satisfied with their condition.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">The study does not support the use of PRFM for augmentation of a double row repair of a small or medium rotator cuff tear to improve healing, although, given the heterogeneity of PRP products on the market, it is possible that other preparations may be more effective.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><b>Specialty Day support</b> </span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Another study on 79 patients who received platelet-rich plasma with a fibrin matrix demonstrated no real differences in healing in a tendon-to-bone rotator cuff repair. In fact, this preliminary analysis suggests that the PRFM, as used in this study, may have a negative effect on healing. However, these data should be viewed as preliminary, and further study is required. </span>The effect of platelet-rich fibrin matrix on rotator cuff tendon healing: A prospective randomized clinical study.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">The randomized trial broke the 79 patients into two groups: those who received the PRFM and those who did not. Standardized rotator cuff repair techniques and postoperative rehabilitation protocols were used for all patients. The tendon healing was evaluated using ultrasound at 6 weeks and 12 weeks after surgery. Ultrasound was also used to determine blood flow in various areas of the repaired tendon. The researchers also looked at shoulder movement outcome scales and strength measurements.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Overall, we found no differences in tendon-to-bone healing between the two groups. Repairs were intact in two thirds of the PRFM group and in 80 percent of the control group. Ultrasound found no significant differences in healing at 6 weeks or at 12 weeks after surgery. Nor were there significant differences in outcome or strength measures.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">The researchers agree that variability in the way platelets are recovered, platelet activation, and the mechanisms for the way the PRFM reacts with the tendon cells may contribute to the contradictory results found in other studies. He also noted that this study was unable to document the number of platelets actually delivered to patients who received the PRFM. </span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Additional research needs to be performed to figure out the mechanisms for why PRP is successful in healing certain areas of the body and not others. With more study we will continue to learn new procedures for improving orthopaedic surgery outcomes.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><br />
</span></div><br />
<div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: xx-small;"><b>Additional Resources:</b><u><a href="http://www3.aaos.org/education/anmeet/anmt2011/podium/podium.cfm?Pevent=577"><br />
The Effect of Platelet-Rich Fibrin Matrix on Rotator Cuff Tendon Healing</a><a href="http://www.sportsmed.org/tabs/search/details.aspx?DID=763"><br />
Specialized Blood Plasma Treatment Does Not Improve Rotator Cuff Healing, Study Finds</a></u></span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><b>Bottom Line</b></span></div><ul compact="compact" style="font-family: "Trebuchet MS",sans-serif;" type="disc"><li><span style="font-size: small;"> Two separate randomized studies found no significant benefit to using PRFM to improve healing after rotator cuff repair.</span></li>
<li><span style="font-size: small;"> One study found more reruptures in the group that did not receive PRFM; the other study found more intact repairs in the group that did not receive PRFM.</span></li>
<li><span style="font-size: small;"> More research is needed to uncover the ways that PRFM reacts with tendons, ligaments, and bones.</span></li>
</ul><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> <span style="font-size: xx-small;">Reference: AAOS <em>Now </em>April 2011 Issue<br />
<a href="http://www.aaos.org/news/aaosnow/apr11/clinical4.asp">http://www.aaos.org/news/aaosnow/apr11/clinical4.asp</a></span></span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Thanks,</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">JTM, MD</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><span style="font-size: xx-small;"> </span></span> </div><div style="font-family: "Trebuchet MS",sans-serif;"></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-20907099519780325102011-03-12T18:26:00.000-05:002011-03-12T18:26:25.488-05:00Complications of Treatment<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Some time ago I wrote a review discussing some of the potential complications of nonsurgical and surgical treatment. When we discuss surgery or nonoperative treatment with patients, we always discuss these issues to the extent that they may relate to your care. Click <a href="http://orthoontheweb.com/pdfs/Complications_of_treatment.pdf">here </a>to download a printable version of that document which is also posted on my website.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-65930120094429337072011-02-03T15:12:00.000-05:002011-02-03T15:12:17.405-05:00Frozen Shoulder = Adhesive Capsulitis: The Stiff Shoulder<div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Stiff shoulders are very common in my practice. Patients often do not even notice that the shoulder is stiff as it is usually a gradual problem </span><span style="font-size: small;">that may be present for a while before patients even notice the loss of motion or the pain that accompanies this condition. </span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move. Frozen shoulder occurs in about 2% of the general population. It most commonly affects people between the ages of 40 and 60, and occurs in women more often than men.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div class="header1" style="font-family: "Trebuchet MS",sans-serif;"> <span style="font-size: small;"><a href="" name="Anatomy"></a>Anatomy</span></div><div class="header1" style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.</span></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="font-family: "Trebuchet MS",sans-serif; margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><img src="http://orthoinfo.aaos.org/figures/A00071F01.jpg" style="clear: both; margin-left: auto; margin-right: auto;" /></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: small;">The shoulder capsule surrounds the shoulder joint and rotator cuff tendons. </span></td></tr>
</tbody></table><div class="header1" style="font-family: "Trebuchet MS",sans-serif;"> <span style="font-size: small;"><a href="" name="Description"></a>Description</span></div><div class="header1" style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint. The hallmark sign of this condition is being unable to move your shoulder - either on your own or with the help of someone else. It develops in three stages:</span></div><div style="font-family: "Trebuchet MS",sans-serif; margin-left: 20px; margin-right: 20px;"> <h4><span style="font-size: small;">Freezing</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span style="font-size: small;">In the"freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.</span></div></div><div style="font-family: "Trebuchet MS",sans-serif; margin-left: 20px; margin-right: 20px;"> <h4><span style="font-size: small;">Frozen</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span style="font-size: small;">Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.</span></div></div><div style="font-family: "Trebuchet MS",sans-serif; margin-left: 20px; margin-right: 20px;"> <h4><span style="font-size: small;">Thawing</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span style="font-size: small;">Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.</span></div><div class="figbox" style="clear: none; float: none; width: 500px;"> <span style="font-size: small;"><img src="http://orthoinfo.aaos.org/figures/A00071F02.jpg" style="clear: both;" /></span><div style="margin: 5px; text-align: left;"><span style="font-size: small;">In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed. </span></div><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"> </div></div></div><div class="pageTop" style="font-family: "Trebuchet MS",sans-serif;"> <span style="font-size: small;"> </span></div><div class="header1" style="font-family: "Trebuchet MS",sans-serif;"> <span style="font-size: small;"><a href="" name="Cause"></a>Cause</span></div><div class="header1" style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"> <span style="font-size: small;"><strong>Diabetes.</strong> Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"> <span style="font-size: small;"><strong>Other diseases.</strong> Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"> <span style="font-size: small;"><strong>Immobilization.</strong> Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div class="header1" style="font-family: "Trebuchet MS",sans-serif;"> <span style="font-size: small;"><a href="" name="Symptoms"></a>Symptoms</span></div><div class="header1" style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.</span></div><br />
<br />
<br />
<div class="header1" style="font-family: "Trebuchet MS",sans-serif;"> <span style="font-size: small;"><a href="" name="Doctor Examination"></a>Doctor Examination</span></div><div style="font-family: "Trebuchet MS",sans-serif; margin-left: 20px; margin-right: 20px;"> <h4><span style="font-size: small;">Physical Examination</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span style="font-size: small;">After discussing your symptoms and medical history, I will examine your shoulder. I will move your shoulder carefully in all directions to see if movement is limited and if pain occurs with the motion. The range of motion when someone else moves your shoulder is called "passive range of motion." We will compare this to the range of motion you display when you move your shoulder on your own ("active range of motion"). People with frozen shoulder have limited range of motion both actively and passively.</span></div></div><div style="font-family: "Trebuchet MS",sans-serif; margin-left: 20px; margin-right: 20px;"> <h4><span style="font-size: small;">Imaging Tests</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span style="font-size: small;">Other tests that may help us rule out other causes of stiffness and pain include:</span></div><div style="margin-top: 0px; padding-top: 0px;"><br />
</div><span style="font-size: small;"><strong>X-rays.</strong> Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in your shoulder, such as arthritis.</span><br />
<br />
<span style="font-size: small;"><strong>Magnetic resonance imaging (MRI) and ultrasound.</strong> These studies can create better images of problems with soft tissues, such as a torn rotator cuff.</span><br />
<br />
</div><div class="header1" style="font-family: "Trebuchet MS",sans-serif;"> <span style="font-size: small;"><a href="" name="Treatment"></a>Treatment</span></div><div class="header1" style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Frozen shoulder generally gets better over time, although it may take up to 3 years.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">The focus of treatment is to control pain and restore motion and strength through physical therapy.</span></div><div style="font-family: "Trebuchet MS",sans-serif; margin-left: 20px; margin-right: 20px;"> <h4><span style="font-size: small;">Nonsurgical Treatment</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span style="font-size: small;">More than 90% of patients improve with relatively simple treatments to control pain and restore motion.</span></div><div style="margin-top: 0px; padding-top: 0px;"><br />
</div><span style="font-size: small;"><strong>Non-steroidal anti-inflammatory medicines.</strong> Drugs like aspirin and ibuprofen reduce pain and swelling.</span><br />
<br />
<span style="font-size: small;"><strong>Steroid injections.</strong> Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint. I generally recommend one injection into the bursa followed by therapy. Two weeks later, I usually inject the shoulder joint itself with a steroid. This is a second injection but it goes into a separate part of the shoulder joint so it does not create any issues with excess cortisone.</span><br />
<span style="font-size: small;"><br />
</span><br />
<span style="font-size: small;"><strong>Physical therapy.</strong> Specific exercises will help restore motion. These may be under the supervision of a physical therapist or via a home program. Therapy includes stretching or range of motion exercises for the shoulder. Sometimes heat is used to help loosen the shoulder up before the stretching exercises.. </span><br />
<br />
<span style="font-size: small;">I advise patients to stretch frequently throughout the day. </span><br />
<span style="font-size: small;">5 minutes of stretching 5 times a day. </span><br />
<span style="font-size: small;">You should feel some stretching but it should not be painful. </span><br />
<span style="font-size: small;">You cannot do all of the exercises in 5 minutes 5 times a day, but patients can do some stretching in that time.</span><br />
<span style="font-size: small;"><br />
</span><br />
<span style="font-size: small;">Below are examples of some of the exercises that might be recommended.</span><br />
<ul><li> <span style="font-size: small;"><strong>External rotation — passive stretch.</strong> Stand in a doorway and bend your affected arm 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30 seconds. Relax and repeat.</span></li>
<div class="figbox" style="clear: none; float: none; width: 250px;"> <span style="font-size: small;"><img src="http://orthoinfo.aaos.org/figures/A00071F04.jpg" style="clear: both;" /></span><div style="margin: 5px; text-align: left;"><span style="font-size: small;">External Rotation - Passive Stretch </span></div><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"><span style="font-size: small;"> <span style="font-size: xx-small;">Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010. </span></span></div><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"><span style="font-size: small;"><span style="font-size: xx-small;"> </span> </span></div></div><li> <span style="font-size: small;"><strong>Forward flexion — supine position.</strong> Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.</span></li>
<div class="figbox" style="clear: none; float: none; width: 250px;"> <span style="font-size: small;"><img src="http://orthoinfo.aaos.org/figures/A00071F05.jpg" style="clear: both;" /></span><div style="margin: 5px; text-align: left;"><span style="font-size: small;">Forward Flexion - Supine Position </span></div><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"><span style="font-size: small;"> <span style="font-size: xx-small;">Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010. </span></span></div><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"><span style="font-size: small;"><span style="font-size: xx-small;"> </span></span></div></div><li> <span style="font-size: small;"><strong>Crossover arm stretch.</strong> Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.</span></li>
<div class="figbox" style="clear: none; float: none; width: 150px;"> <span style="font-size: small;"><img src="http://orthoinfo.aaos.org/figures/A00071F06.jpg" style="clear: both;" /></span><div style="margin: 5px; text-align: left;"><span style="font-size: small;">Crossover Arm Stretch </span></div><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"><span style="font-size: small;"> <span style="font-size: xx-small;">Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.</span> </span></div></div></ul></div><div style="font-family: "Trebuchet MS",sans-serif; margin-left: 20px; margin-right: 20px;"> <h4><span style="font-size: small;">Surgical Treatment</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span style="font-size: small;">If your symptoms are not relieved by therapy and anti-inflammatory medicines, you and your doctor may discuss surgery. It is important to talk with your us about your potential for recovery continuing with simple treatments, and the risks involved with surgery.</span></div><div style="margin-top: 0px; padding-top: 0px;"><br />
</div><span style="font-size: small;">The goal of surgery for frozen shoulder is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy.</span><br />
<br />
<span style="font-size: small;"><strong>Manipulation under anesthesia.</strong> During this procedure, you are put to sleep. Your doctor will force your shoulder to move which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases range of motion.</span><br />
<span style="font-size: small;">I generally do not advise this as there is risk of fracture and rotator cuff tear.</span><br />
<span style="font-size: small;"> </span><br />
<span style="font-size: small;"><strong>Shoulder arthroscopy.</strong> In this procedure, your we will cut through tight portions of the joint capsule. This is done using pencil-sized instruments inserted through small incisions around your shoulder.</span><br />
<br />
<span style="font-size: small;">In many cases, manipulation and arthroscopy are used in combination to obtain maximum results. Most patients have very good outcomes with these procedures.</span><br />
<br />
<span style="font-size: small;">This is my preferred treatment if any procedure for frozen shoulder is advised.</span><br />
<span style="font-size: small;"> </span><br />
<div class="figbox" style="clear: none; float: none; width: 350px;"> <span style="font-size: small;"><img src="http://orthoinfo.aaos.org/figures/A00071F07.jpg" style="clear: both;" /></span><div style="margin: 5px; text-align: left;"><span style="font-size: small;">These photos taken through an arthroscope show a normal shoulder joint lining <strong>(left)</strong> and an inflamed joint lining damaged by frozen shoulder. </span></div><div style="margin: 5px; text-align: left;"><span style="font-size: small;"> </span></div><div style="color: #660000; font-style: italic; margin-left: 5px; margin-right: 5px; text-align: left;"> </div></div><span style="font-size: small;"><strong>Recovery.</strong> After surgery, physical therapy is necessary to maintain the motion that was achieved with surgery. Recovery times vary, from 6 weeks to three months. Some patients will take 6-12 months to achieve maximum recovery. </span><br />
<br />
<span style="font-size: small;"> Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy.</span><br />
<br />
<span style="font-size: small;">Long-term outcomes after surgery are generally good, with most patients having reduced or no pain and greatly improved range of motion. In some cases, however, even after several years, the motion does not return completely and a small amount of stiffness remains.</span><br />
<br />
<span style="font-size: small;">Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present.</span><br />
<br />
<span style="font-size: small;"><a href="http://www.eorthopod.com/eorthopodV2/index.php/fuseaction/topics.detail/ID/11f7bb694c74b0d58e8142662803c0f6/TopicID/320cb98ec05bdb22b9dc76d949bf31c9/area/6">From my web site. </a></span><br />
<br />
<span style="font-size: small;"><span style="font-size: xx-small;"><a href="http://orthoinfo.aaos.org/topic.cfm?topic=A00071">Reference </a></span></span><br />
<br />
<span style="font-size: small;">Thanks,</span><br />
<span style="font-size: small;"> </span><br />
<span style="font-size: small;">JTM, MD</span><br />
</div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-70615868019064527882011-02-02T11:57:00.001-05:002011-02-02T11:57:04.580-05:00Biceps Tendon Tear at the Elbow<div id="rightColumn" style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The biceps muscle is in the front of your upper arm. It helps you bend your elbow and rotate your forearm. It also helps keep your shoulder stable.</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Tendons attach muscles to bones. Your biceps tendons attach the biceps muscle to bones in the shoulder and in the elbow. If you tear the biceps tendon at the elbow, you will lose strength in your arm and be unable to forcefully turn your arm from palm down to palm up.</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Once torn, the biceps tendon at the elbow will not grow back to the bone and heal. Other arm muscles make it possible to bend the elbow fairly well without the biceps. However, they cannot fulfill all the functions, especially the motion of rotating the forearm from palm down to palm up. This is called supination. Significant, permanent weakness during supination will occur if this tendon is not surgically repaired.</span></div><div class="header1" style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Anatomy" style="color: blue;"></a>Anatomy</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The biceps has two tendons that attach the muscle to the bone in the shoulder and one tendon that attaches at the elbow. The tendon at the elbow is also called the distal biceps tendon. It attaches to the radial tuberosity. This is a small bump on one of the bones in your forearm (radius) near your elbow joint.</span></div><div class="header1" style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Description" style="color: blue;"></a>Description</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Biceps tendon tears can be either partial or complete.</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><strong>Partial tears.</strong> These tears do not completely sever the tendon.</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><strong>Complete tears.</strong> A complete tear will split the tendon into two pieces.</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="http://orthoinfo.aaos.org/figures/A00376F01.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" src="http://orthoinfo.aaos.org/figures/A00376F01.jpg" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span class="Apple-style-span" style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; font-size: small;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The biceps muscle helps </span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">you bend and rotate your arm. It attaches at the elbow to the radius bone on a small bump called the radial tuberosity.</span></span></td></tr>
</tbody></table><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"></span></div><div class="separator" style="clear: both; text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><a href="http://orthoinfo.aaos.org/figures/A00376F02.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em;"><img border="0" src="http://orthoinfo.aaos.org/figures/A00376F02.jpg" /></a></span></div><div style="font-family: 'Times New Roman'; margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">A complete tear of the distal biceps tendon. The tendon is detached from the bone.</span></span></div><br />
<div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In most cases, tears of the distal biceps tendon are complete. This means that the entire muscle is detached from the bone and pulled toward the shoulder. Distal biceps tendon rupture is equally likely in the dominant and non-dominant arm.</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Other arm muscles can substitute for the injured tendon, usually resulting in full motion and reasonable function. Left without surgical repair, however, the injured arm will have a 30% to 40% decrease in strength, mainly in twisting the forearm (supination).</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Rupture of the biceps tendon at the elbow is unusual. It occurs in only one to two people per 100,000 each year, and rarely in women.</span></div><div class="header1" style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Cause" style="color: blue;"></a>Cause</span></div><span class="Apple-style-span" style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The main cause of a distal biceps tendon tear is a sudden injury. These tears are rarely associated with other medical conditions.</span></span><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Injury</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Injuries to the biceps tendon at the elbow usually occur when the elbow is forced straight against resistance. It is less common to injure this tendon when the elbow is forcibly bent against a heavy load.</span></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Lifting a heavy box is a good example. Perhaps you grab it without realizing how much it weighs. You strain your biceps muscles and tendons trying to keep your arms bent, but the weight is too much and forces your arms straight. As you struggle, the stress on your biceps increases and the tendon tears away from the bone.</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Risk Factors</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Men, age 30 years or older, are most likely to tear the distal biceps tendon.</span></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Additional risk factors for distal biceps tendon tear include:</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><strong>Smoking.</strong> Nicotine use can affect nutrition in the tendon.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><strong>Corticosteroid medications.</strong> Using corticosteroids has been linked to increased muscle and tendon weakness.</span></div><div class="header1" style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Symptoms" style="color: blue;"></a>Symptoms</span></div><div class="figbox" style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: right; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 20px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 150px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00376F03.jpg" style="clear: both;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">A distal biceps tendon tear can cause the muscle to ball up near the shoulder. Bruising at the elbow is also common.</span></div></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">There is often a "pop" at the elbow when the tendon ruptures. Pain is severe at first, but may subside after a week or two. Other symptoms include:</span></div><ul style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px;"><li style="padding-bottom: 10px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Swelling in the front of the elbow</span></li>
<li style="padding-bottom: 10px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Visible bruising in the elbow and forearm</span></li>
<li style="padding-bottom: 10px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Weakness in bending of the elbow</span></li>
<li style="padding-bottom: 10px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Weakness in twisting the forearm (supination)</span></li>
<li style="padding-bottom: 10px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">A bulge in the upper part of the arm created by the recoiled, shortened biceps muscle</span></li>
<li style="padding-bottom: 10px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">A gap in the front of the elbow created by the absence of the tendon</span></li>
</ul><div class="header1" style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Doctor Examination" style="color: blue;"></a>Doctor Examination</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Medical History and Physical Examination</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">After discussing your symptoms, your doctor will review the events of the injury to determine how it occurred. During the physical examination, your doctor will feel the front of your elbow, looking for a gap in the tendon. He or she will test the supination strength of your forearm by asking you to rotate your forearm against resistance. Your doctor will compare the supination strength to the strength of your opposite, uninjured forearm.</span></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In addition to the examination, your doctor may recommend imaging tests to help confirm a diagnosis.</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Imaging Tests</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><strong>X-rays.</strong> Although X-rays cannot show soft tissues like the biceps tendon, they can be useful in ruling out other problems that can cause elbow pain.</span></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><strong>Magnetic resonance imaging (MRI).</strong> These scans create better images of soft tissues. They can show both partial and complete tears.</span></div><div class="header1" style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; border-bottom-color: rgb(0, 102, 102); border-bottom-style: solid; border-bottom-width: 1px; clear: none; color: #006666; font-weight: bold; margin-bottom: 5px; margin-top: 15px; text-align: left; width: 341px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><a href="" name="Treatment" style="color: blue;"></a>Treatment</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Nonsurgical Treatment</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Nonsurgical treatment may be considered for patients who are elderly and inactive, or who have medical problems that make them high-risk for modest surgery.</span></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Patients must weigh the decision to proceed with nonsurgical treatment carefully, because restoring arm function with later surgery may not be possible.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The tendon should be repaired during the first 2 to 3 weeks after injury. After this time, the tendon and biceps muscle begin to scar and shorten.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">While other options are available for patients requesting late surgical treatment for this injury, they are more complicated and generally less successful.</span></div><div style="-webkit-border-horizontal-spacing: 5px; -webkit-border-vertical-spacing: 5px; margin-left: 20px; margin-right: 20px;"><h4 style="color: #003399; font-style: italic; margin-bottom: 0px; padding-bottom: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Surgical Treatment</span></h4><div style="margin-top: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><strong>Procedure.</strong> Doctors use several procedures to reattach the distal biceps tendon to the forearm bone. Some doctors prefer to use two incisions, while others only one incision. There are pros and cons to each approach.</span></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Sometimes the tendon is attached with stitches through holes drilled in the bone. Other times, small metal implants are used to attach the tendon to the bone.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Be sure to carefully discuss the options available with your doctor.</span><br />
<div class="figbox" style="background-color: white; border-bottom-color: rgb(0, 51, 153); border-bottom-style: solid; border-bottom-width: 1px; border-left-color: rgb(0, 51, 153); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(0, 51, 153); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(0, 51, 153); border-top-style: solid; border-top-width: 1px; clear: none; float: none; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 20px; padding-bottom: 5px; padding-left: 5px; padding-right: 5px; padding-top: 5px; text-align: center; width: 350px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><img src="http://orthoinfo.aaos.org/figures/A00376F04.jpg" style="clear: both;" /></span><div style="margin-bottom: 5px; margin-left: 5px; margin-right: 5px; margin-top: 5px; text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">X-rays showing metal implants called suture anchors that have been used to secure the biceps tendon to the bone.</span></div></div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><strong>Complications.</strong> Surgical complications are generally rare and temporary. They occur in about 6% to 9% of patients.</span><br />
<ul><li style="padding-bottom: 10px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Numbness and/or weakness in the forearm can occur and usually goes away.</span></li>
<li style="padding-bottom: 10px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">New bone may develop around the site where the tendon is attached to the forearm bone. While this usually causes little limitation of movement, sometimes it can reduce the ability to twist the forearm. This requires additional surgery.</span></li>
<li style="padding-bottom: 10px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Rerupture after full healing of the repair is uncommon.</span></li>
</ul><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><strong>Rehabilitation.</strong> Right after surgery, your arm may be immobilized in a cast or splint.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Your doctor will soon begin having you move your arm, often with the protection of a brace. He or she may prescribe physical therapy to help you regain range of motion and strength.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Resistance exercises, such as lightly contracting the biceps or using elastic bands, may be gradually added to your rehabilitation plan.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Be sure to follow your doctor's treatment plan. Since the biceps tendon takes 2 to 3 months to fully heal, it is important to protect the repair by restricting your activities.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Light work activities can begin soon after surgery. But heavy lifting and vigorous activity should be avoided for several months.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Although it is a slow process, your commitment to your rehabilitation plan is the most important factor in returning to all the activities you enjoy.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><strong>Surgical Outcome.</strong> Almost all patients have full range of motion at the final follow-up doctor visit.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">After time, return to heavy activities and jobs involving manual labor is a reasonable expectation.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">From the AAOS.org</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"></span></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-57743918095896718562011-01-04T08:19:00.000-05:002011-01-04T08:19:46.257-05:00Bone Health from the AAOS<div style="font-family: "Trebuchet MS",sans-serif;">The American Academy of Orthopedic Surgeons does a great job of developing and promoting patient education topics online. I cannot reproduce all of the work they have done but we can certainly link to and my patients can benefit from their efforts. The AAOS site on bone health and osteoporosis is called <a href="http://www.ownthebone.org/patients">Own the Bone</a>.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">Thanks,</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">JTM, MD</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-69823980907276560922010-12-23T09:53:00.000-05:002010-12-23T09:53:56.395-05:00Skate, Slide and Glide Through Winter Injury-free<div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/_7o9rCA8Mqao/TRNiTYtaT0I/AAAAAAAABDA/HGbFim3rJ_c/s1600/images1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://4.bp.blogspot.com/_7o9rCA8Mqao/TRNiTYtaT0I/AAAAAAAABDA/HGbFim3rJ_c/s1600/images1.jpg" /></a></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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 <a href="http://www.aaos.org/">American Academy of Orthopaedic Surgeons</a>’(AAOS) on-going <a href="http://www6.aaos.org/about/pemr/pia/pep_prevent.cfm">Prevent Injuries America</a>!® campaign, the AAOS urges children and adults to consider these winter sports injury prevention tips before braving the snow.</div><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/_7o9rCA8Mqao/TRNiY7_goMI/AAAAAAAABDE/IoENPLou4fk/s1600/sports019viafuntasticuspc0.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="250" src="http://4.bp.blogspot.com/_7o9rCA8Mqao/TRNiY7_goMI/AAAAAAAABDE/IoENPLou4fk/s400/sports019viafuntasticuspc0.jpg" width="400" /></a></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">STATISTICS:</div><ul style="font-family: "Trebuchet MS",sans-serif;"><li>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,</li>
</ul><div style="font-family: "Trebuchet MS",sans-serif;">AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS SAFETY TIPS:</div><ul style="font-family: "Trebuchet MS",sans-serif;"><li>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.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>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. </li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>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.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><ul><li>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.</li>
</ul></ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>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.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>Skiers and snowboarders should stay on marked trails and avoid potential avalanche areas such as steep hillsides with little vegetation.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>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.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>Sit in a forward-facing position when sledding and steer using your feet or the rope steering handles for better control of the sled.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>Warm up thoroughly before playing. Cold muscles, tendons and ligaments are vulnerable to injury.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><ul><li>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.</li>
</ul></ul><ul style="font-family: "Trebuchet MS",sans-serif;"><ul><li>Skiers and snowboarders should take a couple of slow runs to warm up.</li>
</ul></ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>Drink plenty of water before, during, and after outdoor activities. Don’t drink alcohol as it can increase your chances of hypothermia.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>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.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>Know and abide by all rules of the sport in which you are participating.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>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.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><ul><li>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.</li>
</ul></ul><ul style="font-family: "Trebuchet MS",sans-serif;"><ul><li>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.</li>
</ul></ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>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.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>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.</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>If injured during any winter excursion and pain or discomfort persists, follow up with an orthopedic surgeon to examine the injury.</li>
</ul><span style="font-size: xx-small;"><a href="http://www6.aaos.org/news/pemr/releases/release.cfm?releasenum=942"><span style="font-family: "Trebuchet MS",sans-serif;">Reference</span></a></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br />
</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">Thanks,</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br />
</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">JTM, MD</span>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-43370320405800079092010-12-22T09:56:00.000-05:002010-12-22T09:56:47.573-05:00More Complications with Single-incision Repair of Biceps Ruptures from the Elbow<div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/_7o9rCA8Mqao/TRIQUNoh4lI/AAAAAAAABCs/qt2o0ZMGwds/s1600/distal+biceps1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://1.bp.blogspot.com/_7o9rCA8Mqao/TRIQUNoh4lI/AAAAAAAABCs/qt2o0ZMGwds/s1600/distal+biceps1.jpg" /></a></div><h1 style="line-height: 16px; margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; font-size: small; font-weight: normal; line-height: normal;">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 <i>selected cases</i>. </span></h1><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/_7o9rCA8Mqao/TRIQn9BXTsI/AAAAAAAABCw/deWOULeGj4M/s1600/2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://4.bp.blogspot.com/_7o9rCA8Mqao/TRIQn9BXTsI/AAAAAAAABCw/deWOULeGj4M/s1600/2.jpg" /></a></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; font-size: small; font-weight: normal; line-height: normal;"><br />
</span></div><h1 style="line-height: 16px; margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; font-size: small;"><span class="Apple-style-span" style="font-weight: normal;">Read on from the AAOS...</span></span></h1><h1 style="color: #990000; line-height: 16px; margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="color: black; font-family: 'Trebuchet MS', sans-serif; font-size: small; font-weight: normal;">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.</span></h1><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://1.bp.blogspot.com/_7o9rCA8Mqao/TRIQwOZzLqI/AAAAAAAABC0/tR7irOpjHso/s1600/3.+biceps.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="http://1.bp.blogspot.com/_7o9rCA8Mqao/TRIQwOZzLqI/AAAAAAAABC0/tR7irOpjHso/s1600/3.+biceps.JPG" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">An intra operative photo of a single incision repair using endobutton anchor. This ruptured tendon will be reinserted into the bone.</span></td></tr>
</tbody></table><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">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).</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">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; <i>p</i> = 0.01).</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><i>JTM comment: Double incision technique seems to result in superior strength at least in this study.</i></span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Overall, 19 of 48 patients in the single-incision group had complications, compared to 3 of 42 in the double-incision group (<i>p</i> < 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. </span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><i>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.</i></span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">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.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><i>JTM comment: Tendons re-ruptured because patients did not listen to the doctor. Where have I heard this before.</i></span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Bottom line</b></span></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://1.bp.blogspot.com/_7o9rCA8Mqao/TRIRXk_hfUI/AAAAAAAABC4/RsuZjyvavgU/s1600/4.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="http://1.bp.blogspot.com/_7o9rCA8Mqao/TRIRXk_hfUI/AAAAAAAABC4/RsuZjyvavgU/s1600/4.jpg" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The perfect repair.</span></td></tr>
</tbody></table><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" /></b>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.</span></div><ul compact="" style="line-height: 16px; margin-bottom: 0.7em; margin-left: 1.5em; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" type="disc"><li style="margin-bottom: 0.5em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The single-incision group had a greater incidence of complications.</span></li>
</ul><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; font-size: xx-small;">AAOS <em>Now </em>December 2010 Issue <a href="http://www.aaos.org/news/aaosnow/dec10/clinical9.asp" style="color: #003399;">http://www.aaos.org/news/aaosnow/dec10/clinical9.asp</a></span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">You can get some additional information on biceps tendon ruptures at the elbow <a href="http://orthoontheweb.com/pdfs/BoomeritisElbowProblemsintheMatureAthlete.pdf">here </a>and <a href="http://www.eorthopod.com/eorthopodV2/index.php/fuseaction/topics.detail/ID/11f7bb694c74b0d58e8142662803c0f6/TopicID/34ffbd965d3b9e5830200ca769d460e2/area/8">here</a> and <a href="http://a.blip.tv/scripts/flash/stratos.swf?file=http://blip.tv/rss/flash/1764297&showplayerpath=http://a.blip.tv/scripts/flash/stratos.swf&feedurl=http://eorthopodtv.blip.tv/rss/flash&brandname=eorthopod.tv&brandlink=http://eorthopod.tv/&enablejs=true&showguidebutton=false&lightcolor=0xFFFFFF&backcolor=0x000000&referrer=http%253A%252F%252Forthoontheweb.com%252Forthopedic_library.asp&source=3">here</a>.</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br />
</div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Thanks,</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div><div style="line-height: 16px; margin-bottom: 0.7em; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">JTM, MD</span></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-11761500169487752582010-12-08T08:11:00.001-05:002010-12-08T08:12:11.247-05:00The Latest Study on Glucosamine and Chondroitin: Not good<div style="font-family: "Trebuchet MS",sans-serif;"></div><div id="bodypadding" style="font-family: "Trebuchet MS",sans-serif;"><div id="contentbody"><div id="articlecontent"><div id="postingdate">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.</div><div id="postingdate"><br />
</div><div id="postingdate">Here is the latest from Journal Watch. 2010;30(21) © 2010 Massachusetts Medical Society</div><h4>Summary</h4>Alone or in combination, the supplements do not reduce joint pain or limit joint-space narrowing.<br />
<h4>Introduction</h4>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 (<i>JW Gen Med</i> Mar 15 2006, p. 45, and <i>N Engl J Med</i> 2006; 354:795).<br />
<br />
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.<br />
<br />
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.<i> </i><br />
<br />
<i> 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</i><br />
<br />
<b>The Bottom Line</b><br />
<br />
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.<br />
<br />
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.<br />
<div class="inactive" id="references"><div class="closewindow2"><br />
</div><div class="closewindow2">It does not seem to work, save your money, according to this study.</div><div class="layerbg2"><div class="scrolllayer"><h4><span style="font-size: xx-small;">References</span></h4><ul><li><span style="font-size: xx-small;">Wandel S et al. Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: Network meta-analysis. <i>BMJ</i> 2010 Sep 16; 341:c4675.</span></li>
</ul></div></div></div></div><div id="legaltextsection">Thanks,<br />
<br />
JTM, MD</div></div><div id="bottomspacer"></div></div><img alt="" border="0" src="http://bi.medscape.com/pi/1x1/pv/www-1x1.gif?1291813210917" style="font-family: "Trebuchet MS",sans-serif;" />Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-15091211992686471062010-12-07T17:04:00.001-05:002010-12-08T07:55:31.575-05:00Treating tendinopathy with PRP<h1 style="font-family: "Trebuchet MS",sans-serif;"></h1><div style="font-family: "Trebuchet MS",sans-serif;">Below is a report from the AAOS web site. Unabridged and unaltered.</div><div style="font-family: "Trebuchet MS",sans-serif;"></div><div style="font-family: "Trebuchet MS",sans-serif;">It is in response to several questions this week about PRP. Enjoy.<b><br />
</b></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b>Letha Y. Griffin, MD, leads a focused roundtable</b></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"></div><table style="font-family: "Trebuchet MS",sans-serif;"><tbody>
<tr> <td valign="top" width="590"><img border="1" height="250" src="http://www.aaos.org/news/aaosnow/sep10/clinical2-1.gif" width="300" /></td></tr>
<tr> <td valign="top" width="590"><i>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</i><br />
<br />
</td></tr>
</tbody></table><div style="font-family: "Trebuchet MS",sans-serif;">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. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b>Dr. Griffin:</b> <b><i>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?</i></b></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b>Dr. Cole:</b> 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. </div><div style="font-family: "Trebuchet MS",sans-serif;">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.<br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.<br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b>Dr. Mandelbaum:</b> 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. </div><div style="font-family: "Trebuchet MS",sans-serif;">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.<br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b><i>Dr. Griffin: Dr. Arnoczky and Dr. Andrews, could you summarize your thoughts on the effectiveness of PRP injections in treating tendinopathy? </i></b></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b>Dr. Arnoczky:</b> 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. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b>Dr. Andrews:</b> 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. </div><div style="font-family: "Trebuchet MS",sans-serif;">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. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.<br />
<br />
<i>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. </i></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b><i>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?</i></b></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b>Dr. Rodeo:</b> 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. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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 <br />
<br />
<i>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.</i> <i>We do not heal tendons faster just because the skin incision is smaller.</i></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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:</div><ul compact="compact" style="font-family: "Trebuchet MS",sans-serif;" type="disc"><li> What is the best time for injection?</li>
<li> Are there different effects on acutely injured tendon versus degenerative tendon?</li>
<li> Is there a risk of increasing inflammation?</li>
<li> Would serial injections be more effective?</li>
<li> What is the effect of pH on cytokine release?</li>
<li> What are the kinetics of cytokine release?</li>
</ul><i><span style="font-family: "Trebuchet MS",sans-serif;">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</span><span style="font-family: "Trebuchet MS",sans-serif;"> and get it to heal. That is fantasy at this time.</span></i><br />
<ul compact="compact" style="font-family: "Trebuchet MS",sans-serif;" type="disc"></ul><div style="font-family: "Trebuchet MS",sans-serif;"><b><i>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?</i></b></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b>Dr. Maffulli:</b> 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. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b>Dr. Mandelbaum:</b> 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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b><i>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? </i></b></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b>Dr. Arnoczky:</b> 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. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b>Dr. Cole:</b> 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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">Finally, we really do not yet understand the proper dose, frequency, and timing of PRP application for any specific condition. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b><i>Dr. Griffin: Dr. Andrews, hearing these responses, how would you summarize our knowledge of the use of PRP to treat tendinosis or tendinopathy? </i></b></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><b>Dr. Andrews:</b> 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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">Interesting but not yet ready for prime time.<br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"></div><div style="font-family: "Trebuchet MS",sans-serif;">Thanks,</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">JTM, MD</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-54827348161733145162010-12-07T14:54:00.000-05:002010-12-07T14:54:19.524-05:00Battling a Biceps Injury<div style="font-family: "Trebuchet MS",sans-serif;"><strong></strong><em>New study finds early surgical treatment improves level of recovery in both function and strength</em></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"></div><div style="font-family: "Trebuchet MS",sans-serif;">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 <em>Journal of the American Academy of Orthopaedic Surgeons</em><em></em> (JAAOS). </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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:<br />
</div><ul style="font-family: "Trebuchet MS",sans-serif;"><li>allowing the elbow to bend (elbow flexion), and</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>allowing the arm to turn the palm upward (supination).</li>
</ul><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">The results of the study also indicate surgery is most effective, and much simpler, when completed within two weeks of the initial injury.</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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:<br />
</div><ul style="font-family: "Trebuchet MS",sans-serif;"><li>a “popping” sensation in the arm and bruising around the elbow at the time of injury; </li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>a change in the contour or shape of the biceps muscle; and</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>pain and weakness in flexion and supination of the injured arm</li>
</ul><div style="font-family: "Trebuchet MS",sans-serif;">People can help prevent biceps injuries by:<br />
</div><ul style="font-family: "Trebuchet MS",sans-serif;"><li>avoiding smoking and anabolic steroid use, which decrease blood flow to the tendon, increasing the likelihood of injury;</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>avoiding lifting heavy weights using a biceps curl; and</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>exercising caution when moving heavy objects, especially in individuals who smoke, take steroids, or are older than 30.</li>
</ul><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">For more information on the distal biceps tendon click <a href="http://www.eorthopod.com/eorthopodV2/index.php/fuseaction/topics.detail/ID/11f7bb694c74b0d58e8142662803c0f6/TopicID/34ffbd965d3b9e5830200ca769d460e2/area/8">here</a>.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">For an interview about distal biceps ruptures, click <a href="http://a.blip.tv/scripts/flash/stratos.swf?file=http%3A%2F%2Fblip.tv%2Frss%2Fflash%2F1764297&showplayerpath=http%3A%2F%2Fa.blip.tv%2Fscripts%2Fflash%2Fstratos.swf&feedurl=http%3A%2F%2Feorthopodtv.blip.tv%2Frss%2Fflash&brandname=eorthopod.tv&brandlink=http%3A%2F%2Feorthopod.tv%2F&enablejs=true&showguidebutton=false&lightcolor=0xFFFFFF&backcolor=0x000000&referrer=http%253A%252F%252Fwww.drmazzara.com%252Forthopedic_library.asp&source=3">here</a>. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">More elbow tendon stuff <a href="http://www.drmazzara.com/pdfs/BoomeritisElbowProblemsintheMatureAthlete.pdf">here</a>.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">Thanks,</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">JTM, MD</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-23130950355788770672010-12-07T12:56:00.000-05:002010-12-07T12:56:14.069-05:00Lucky Break: Quit Smoking after Fracture Surgery for Better Healing<div style="font-family: "Trebuchet MS",sans-serif;"><b></b><i>Study finds patients who avoid tobacco for six weeks after surgery have fewer postoperative complications</i></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/_7o9rCA8Mqao/TP5070wbfvI/AAAAAAAABCk/qK72f_-a5-s/s1600/images.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://3.bp.blogspot.com/_7o9rCA8Mqao/TP5070wbfvI/AAAAAAAABCk/qK72f_-a5-s/s1600/images.jpg" /></a></div><div style="font-family: "Trebuchet MS",sans-serif;"><i> </i>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).</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">Smoking inhibits circulation and lowers blood oxygen levels, which can affect short-term and long-term healing in several ways, including:</div><ul style="font-family: "Trebuchet MS",sans-serif;"><li>failure or delayed healing of bone, skin and other soft tissues; or</li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li>causing wound site infections.</li>
</ul><div style="font-family: "Trebuchet MS",sans-serif;">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.</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">Stop smoking. </div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;">Thanks,<br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"></div><div style="font-family: "Trebuchet MS",sans-serif;">JTM, MD</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-5036891362124971703.post-35843168233500752662010-12-07T11:56:00.000-05:002010-12-07T11:56:32.467-05:00Treatment Trends for Biceps Injuries<div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><em>From AAOS.org.</em></span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><em> </em></span></div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><em>For patients with tendinopathy both surgical and nonsurgical treatments show promise, need more study</em></span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">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.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">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.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Statistics:</span> </div><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">Recent studies reported no significant difference in function or patient satisfaction between the two primary surgical options, biceps tenotomy or tenodesis.</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">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.</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">Both surgical treatments for LHB tendinopathy are statistically successful, with a complication rate of less than 1 percent.</span></li>
</ul><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Trends noted:</span> </div><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">Both surgical options -- biceps tenotomy and tenodesis (between which the article found no preference) now can be performed via arthroscopy.</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">The authors agree that nonsurgical treatment is the first – and in many cases may be the only –treatment necessary.</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">The authors of this review seem to agree that of the two surgical options, biceps tenodesis should be used in younger, active patients.</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">The first line of treatment for LHB tendinopathy is a variety of nonsurgical options, such as:</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><ul><li><span style="font-size: small;">Rest;</span></li>
</ul></ul><ul style="font-family: "Trebuchet MS",sans-serif;"><ul><li><span style="font-size: small;">anti-inflammatory drugs;</span></li>
</ul></ul><ul style="font-family: "Trebuchet MS",sans-serif;"><ul><li><span style="font-size: small;">activity modification; and</span></li>
</ul></ul><ul style="font-family: "Trebuchet MS",sans-serif;"><ul><li><span style="font-size: small;">physical therapy.</span></li>
</ul></ul><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">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.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Symptoms:</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">See your doctor or orthopaedic surgeon if you experience any of these symptoms.</span></div><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">Sudden, sharp pain in the upper arm</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">Audible popping or snapping in the shoulder or elbow</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">Cramping of the biceps muscle with strenuous use of the arm</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">Bruising from the middle of the upper arm down toward the elbow</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">Pain or tenderness at the shoulder and the elbow</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">Weakness in the shoulder and the elbow</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">Difficulty turning the palm of the hand up or down</span></li>
</ul><ul style="font-family: "Trebuchet MS",sans-serif;"><li><span style="font-size: small;">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.</span></li>
</ul><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">More on the shoulder biceps tendon <a href="http://www.eorthopod.com/eorthopodV2/index.php/fuseaction/topics.detail/ID/11f7bb694c74b0d58e8142662803c0f6/TopicID/19c1c713b193e533dd633d82b5e6152c/area/6">here</a>.</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Thanks</span></div><div style="font-family: "Trebuchet MS",sans-serif;"><br />
</div><div style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">JTM, MD</span></div>Unknownnoreply@blogger.com