Ortho On The Web Newsletter

Post Arthroscopy Osteonecrosis of the Knee

2012-01-23T17:19:00.000-05:00

Osteonecrosis is the death of bone tissue. There are three types of knee osteonecrosis: 1) spontaneous (occurs without a known cause), 2) post-arthroscopy (occurs after an arthroscopic procedure), and 3) secondary to some other condition such as lupus, use of steroids, or alcohol abuse.

Spontaneous osteonecrosis of the knee is also referred to as SPONK. 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 femur(thighbone) called the femoral condyle is affected most of the time.

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.

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.)

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.

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.

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 bisphosphonates. Knee pain can be managed with analgesics (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.

Another newer drug treatment for knee osteonecrosis is tumor necrosis factor alpha (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.

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 core decompression. Debridement (scraping the damaged area) followed by bone grafting to replace the missing bone has also been tried.

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 unicompartmental knee arthroplasty. 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.

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.

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.

Bisphosphonate treatment for knee osteonecrosis offered rapid pain relief and radiological consolidation of the osteonecrotic area, according to Swiss researchers.

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.

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.

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 (P < .001). The VAS decreased by 80% at 6 months (P <. 001). Fifteen of 28 patients had complete symptom resolution at 6 months follow-up; 6 patients had minimal symptoms (VAS 1 or 2).Magnetic resonance imaging revealed that in 18 of 28 patients, bone marrow edema completely resolved. 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.

Two patients had an unsatisfactory treatment effect; they both underwent arthroplasty.

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.

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.

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.

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.

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 .

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.

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.

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.

So what's the point.

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".

We do not really know what causes post arthroscopy osteonecrosis in these knees.

The references for the science are below. The patients are mine.

Thanks,

JTM, MD

References:

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

Bisphosphonates may offer benefit for knee osteonecrosis

Kraenzlin ME, Graf C, Meier C, et al. Knee Surg Sports Traumatol Arthrosoc. DOI 10.1007/s00167-008-0673-0

Knee Replacement Surgery

2012-01-19T15:47:00.000-05:00

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.

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.

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.

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.

Anatomy

Normal knee anatomy.

The knee is the largest joint in the body and having healthy knees is required to perform most everyday activities.

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.

The menisci are located between the femur and tibia. These C-shaped wedges act as "shock absorbers" that cushion the joint.

Large ligaments hold the femur and tibia together and provide stability. The long thigh muscles give the knee strength.

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.

Normally, all of these components work in harmony. But disease or injury can disrupt this harmony, resulting in pain, muscle weakness, and reduced function.

Cause

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.

Osteoarthritis. 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.
Rheumatoid arthritis. 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."
Post-traumatic arthritis. 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.

Osteoarthritis often results in bone rubbing on bone. Bone spurs are a common feature of this form of arthritis.

Description

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.

There are four basic steps to a knee replacement procedure.

Prepare the bone. The damaged cartilage surfaces at the ends of the femur and tibia are removed along with a small amount of underlying bone.
Position the metal implants. 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.
Resurface the patella. 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.
Insert a spacer. A medical-grade plastic spacer is inserted between the metal components to create a smooth gliding surface.

(Left) Severe osteoarthritis. (Right) 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.

Is Total Knee Replacement for You?

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.

When Surgery Is Recommended

There are several reasons why your doctor may recommend knee replacement surgery. People who benefit from total knee replacement often have:

A knee that has become bowed as a result of severe arthritis.

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
Moderate or severe knee pain while resting, either day or night
Chronic knee inflammation and swelling that does not improve with rest or medications
Knee deformity — a bowing in or out of your knee
Failure to substantially improve with other treatments such as anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy, or other surgeries

Candidates for Surgery

There are no absolute age or weight restrictions for total knee replacement surgery.

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.

Orthopaedic Evaluation

An evaluation with an orthopaedic surgeon consists of several components:

A medical history. 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.
A physical examination. This will assess knee motion, stability, strength, and overall leg alignment.
X-rays. These images help to determine the extent of damage and deformity in your knee.
Other tests. 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.

(Left) In this x-ray of a normal knee, the space between the bones indicates healthy cartilage (arrow). (Right) This x-ray of an arthritic knee shows severe loss of joint space and bone spurs (arrows).

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.

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.

Deciding to Have Knee Replacement Surgery

Realistic Expectations

An important factor in deciding whether to have total knee replacement surgery is understanding what the procedure can and cannot do.

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.

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.

Realistic activities following total knee replacement include unlimited walking, swimming, golf, driving, light hiking, biking, ballroom dancing, and other low-impact sports.

With appropriate activity modification, knee replacements can last for many years.

Possible Complications of Surgery

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.

Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.

Blood clots may develop in leg veins.

Infection. 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.

Blood clots. 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.

Implant problems. 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.

Continued pain. 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.

Neurovascular injury. While rare, injury to the nerves or blood vessels around the knee can occur during surgery.

Preparing for Surgery

Medical Evaluation

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.

Tests

Several tests, such as blood and urine samples, and an electrocardiogram, may be needed to help your orthopaedic surgeon plan your surgery.

Medications

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.

Dental Evaluation

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.

Urinary Evaluations

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.

Social Planning

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.

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.

Home Planning

Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:

Safety bars or a secure handrail in your shower or bath
Secure handrails along your stairways
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
A toilet seat riser with arms, if you have a low toilet
A stable shower bench or chair for bathing
Removing all loose carpets and cords
A temporary living space on the same floor because walking up or down stairs will be more difficult during your early recovery

Your Surgery

You will most likely be admitted to the hospital on the day of your surgery.

Anesthesia

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.

Procedure

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.

Different types of knee implants are used to meet each patient's individual needs.

(Left) An x-ray of a severely arthritic knee. (Right) 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.

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.

Your Hospital Stay

You will most likely stay in the hospital for several days.

Pain Management

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.

Blood Clot Prevention

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.

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.

Physical Therapy

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. 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.

Preventing Pneumonia

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.

Your Recovery at Home

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.

Wound Care

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.

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.

Diet

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.

Activity

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.

Your activity program should include:

A graduated walking program to slowly increase your mobility, initially in your home and later outside
Resuming other normal household activities, such as sitting, standing, and climbing stairs
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.

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.

Avoiding Problems After Surgery

Blood Clot Prevention

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.

Warning signs of blood clots. The warning signs of possible blood clots in your leg include:

Increasing pain in your calf
Tenderness or redness above or below your knee
Increasing swelling in your calf, ankle, and foot

Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include:

Sudden shortness of breath
Sudden onset of chest pain
Localized chest pain with coughing

Preventing Infection

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.

After your knee replacement, you must take preventive antibiotics before dental or surgical procedures that could allow bacteria to enter your bloodstream.

Warning signs of infection. Notify your doctor immediately if you develop any of the following signs of a possible knee replacement infection:

Persistent fever (higher than 100°F orally)
Shaking chills
Increasing redness, tenderness, or swelling of the knee wound
Drainage from the knee wound
Increasing knee pain with both activity and rest

Avoiding Falls

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.

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.

Outcomes

How Your New Knee Is Different

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.

Most people feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending activities.

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.

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.

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.

Protecting Your Knee Replacement

After surgery, make sure you also do the following:

Participate in regular light exercise programs to maintain proper strength and mobility of your new knee.
Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery.
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.
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.

Extending the Life of Your Knee Implant

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.

Here is a link to other knee replacement information on my web site.

Reference

Thanks,

JTM, MD

Wrist Fractures

2012-01-19T15:17:00.000-05:00

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.

Cause

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.
Sometimes, the other bone of the forearm (the ulna) is also broken. When this happens, it is called a distal ulna fracture.
This fracture was first described by an Irish surgeon and anatomist, Abraham Colles, in 1814; hence the name, "Colles " fracture.

Symptoms

A broken wrist usually causes immediate (acute) pain, tenderness, bruising, and swelling. Frequently, the wrist hangs in an odd or bent way (deformity).

Diagnosis

The doctor will take an X-ray of the wrist. This is important to understand the extent of the injury.
The fracture almost always occurs about 1 inch from the end of the bone. The break (fracture) can occur in many different ways, however.
A fracture that extends into the joint, it is called an intra-articular fracture.
A fracture that does not extend into the joint is called an extra-articular fracture. ("Articular" means "joint.")
When a fractured bone breaks the skin, it is called an open fracture.
When a bone is broken into more than two pieces, it is called a comminuted fracture.
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.

Risk Factors

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.
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.
Good bone health remains an important prevention option. Wrist guards may help to prevent some fractures, but they will not prevent them all.

Treatment

Immediate Treatment

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.

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.

Nonsurgical Treatment

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.

Casting: If the broken bone is in a good position, a plaster cast may be applied until the bone heals.
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).
If the bone is straightened (reduced) without having to open the skin (incision), this is called a closed reduction.

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.
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.
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.

Surgical Treatment

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.
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.
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.

After Surgery

What can I expect while my bone is healing?

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.

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.
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.
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.
Most surgical incisions must be kept clean and dry for five days or until the sutures (stitches) are removed, whichever occurs later.

What can I expect after my bone has healed?

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.

Some generalizations can be made.

The cast is usually removed at about six weeks.
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.
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.
Most patients can resume vigorous physical activities, such as skiing or football, between three and six months after the injury.
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.
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.

Remember, these are general guidelines and may not apply to you and your fracture. Ask us for specifics in your case.

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.

From the AAOS

If you go here 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.

Thanks,

JTM, MD

Starting a Strength Training Program

2012-01-19T15:04:00.000-05:00

Exercise programs that get the best results are made up of three main elements: aerobic conditioning, flexibility exercises, and strength training.
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).

The Benefits of Strength Training

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.
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.

Strength Training Equipment

Strength training is typically done with free weights and weight machines. Both are effective ways to improve muscle strength and endurance.
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.
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.
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.
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.
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.

Beginning a Strength Training Program

Exercise Safety

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.

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.
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.

An Effective Strength Program

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.

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.
Your program should include exercises for all of the major muscle groups. Muscle imbalances are a major cause of injury.
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.
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.
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.

From the AAOS

Thanks,

JTM, MD

Starting an Exercise program

2012-01-19T14:57:00.000-05:00

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.
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.
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.

Prepare for Success

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.
Take plenty of time to warm up and cool down with walking and gentle stretching exercises.

Selecting Exercise Activities

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.

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.
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.

Ensuring Proper Equipment

Shoes. 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.

Home equipment. 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.
New technology. 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.
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.
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.

A Balanced Exercise Program

Exercise programs that get the best results are made up of three main elements: aerobic conditioning, flexibility exercises, and strength training.

Aerobic Conditioning

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.

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.
Examples of aerobic exercise include walking, jogging, and biking. Many people prefer using machines, such as rowing machines, stair climbers, or treadmills.

Flexibility Exercises

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.

If improved flexibility is one of your fitness goals, specific activities, like yoga and tai chi, provide effective flexibility training.

Strength Training

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.

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).

Establish a Reasonable Schedule

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.
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.

Stick With It

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.
There are many things you can do to help you stick with your exercise program.

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.
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.
Exercising with a friend often helps both people stay motivated and on track.
Work towards an exercise goal, such as finishing a 5k run or participating in a group hiking trip.
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.
Do not stop your fitness program — the benefits from exercise begin to diminish in 2 weeks and disappear in 2 to 8 months.
Congratulate yourself for each accomplishment.

Thanks to the AAOS for the above.

Thanks,

JTM, MD

A Study on Bilateral Knee Replacements

2012-01-19T14:51:00.000-05:00

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 complications for these procedures in higher than if the knees were replaced one at a time or if they were staged three weeks apart.

Here is a study that addresses this issue. Read on...

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.

“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 Anesthesia & Analgesia.

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. Studies have shown that bilateral knee replacements, however, are associated with greater morbidity and mortality than unilateral knee replacements.

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.

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. 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.

“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.

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.”

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.”

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.

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.
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.

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.

Thanks,

JTM, MD

2011-10-19T14:10:00.000-04:00

Herbal Supplements May Cause Dangerous Drug Interactions in Orthopaedic Surgery Patients
Discontinuing use prior to surgery can help avoid adverse events

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 Journal of the American Academy of Orthopaedic Surgeons (JAAOS).

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.

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.

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.

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.

Many of the most popular herbal supplements used today can have serious side effects when combined with prescription medicines. For example:

Feverfew (used for migraine prevention), ginger, cranberry, St. John’s Wort and ginseng can interact with the anti-clotting drug warfarin;
Feverfew, ginger, and gingko can interact with aspirin;
Garlic can interfere with anti-clotting medications and the immunosuppressant drug cyclosporine (prevents transplant rejection);
Valerian (used as a sedative) can intensify anesthetics; and
St. John’s Wort can interact with immunosuppressive drugs and potentially lead to transplant rejection.

Herbal products marketed for osteoarthritis also can pose serious risks when combined with prescription medications. For example:

Glucosamine, chondroitin and flavocoxid can affect clotting agents;
Black cohosh can interact with the cancer drug tamoxifen; and
Cat’s claw can interact with clotting agents, blood pressure medications and cyclosporine.

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.

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.

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.

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.

From the AAOS

Thanks,

JTM, MD

Rotator Cuff Tears: Frequently Asked Questions

2011-10-19T14:01:00.000-04:00

From the AAOS.org

What is the rotator cuff and what does it do?

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.

The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint.

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.

What causes a rotator cuff tear and how would I know if I have one?

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.

If the tear occurs with injury you may experience acute pain, a snapping sensation, and immediate weakness of the arm.

If I have a painful rotator cuff and keep using it, will this cause further damage?

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.

If you know you have a rotator cuff tear, then worsening pain and decreasing strength may mean the tear is getting larger.

When should I see a doctor for a rotator cuff tear?

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.

Early diagnosis and treatment of a rotator cuff tear may prevent symptoms such as loss of strength and loss of motion from setting in.
If your primary physician has already made the diagnosis, an orthopaedic surgeon can review both surgical and nonsurgical options and start treatment.

Can a rotator cuff tear be healed or strengthened without surgery?

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.

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

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.

At what point does a rotator cuff tear require surgery to fix it?

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.
Surgery is also indicated in active individuals who use the arm for overhead work or sports. Pitchers, swimmers, and tennis players are common examples.

What options are available for surgical repair?

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 débridement will depend on the degree or the tear. 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.

Three techniques are used for rotator cuff repair: traditional open repair, mini-open repair, and arthroscopic repair.

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

How important is rehabilitation in the treatment of a rotator cuff tear?

Rehabilitation plays a critical role in both the nonsurgical and surgical treatment of a rotator cuff tear.

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.

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.
Dr Mazzara can prescribe an appropriate program based on your needs and the findings at surgery.

Thanks,

JTM, MD

Introduction to Chondroprotection

2011-05-18T09:37:00.000-04:00

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 reference that explores the issue of protecting what cartilage remains in the arthritis joint.

Introduction
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.

We will review briefly the potential molecular targets, the agents thus far developed, and the evidence for their use.

Potential Targets
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.)

Doxycycline and Diacerein
Tetracyclines appear to be inhibitors of several MMPs, including collagenase and gelatinase,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.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.  The data on structural benefits, however, are weak.

Hyaluronan
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.

Vitamins
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.  The data supporting their use are limited, and toxicity at high doses is a concern for several, including vitamin D.

Herbals
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.Data on structural modification are lacking for both of these agents.

Glucosamine and Chondroitin
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.  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,but the results were heterogeneous, making interpretation difficult.

Clinical Guidelines
Clinical guidelines vary for each of the agents currently available. Several support the use of hyaluronan, glucosamine, and chondroitin,while the American Academy of Orthopaedic Surgeons does not recommend use of either. 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.

Summary
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.

Reference

A very nice summary.

Thanks,

JTM, MD

What causes tendon wear and tear called tendinopathy?

2011-05-15T19:21:00.000-04:00

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.

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. 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.

Fig. 1 Histologic appearance of tendinosis tissue shows a characteristic pattern of fibroblasts and vascular, atypical, granulation-like tissue. Courtesy of Scott A. Rodeo, MD

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.

In addition, he noted, there may be an important interaction among load, inflammatory mediator expression, and matrix metalloproteinase (MMP) expression at the microscopic level.

Tendon overload vs. “underload”

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.

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.

This collagenase production may weaken the tendon and put more of the extracellular matrix at risk for further damage during subsequent loading.

More than a decade of research has shown that microscopic collagen fiber failure may play an important role in the development of tendinopathy.

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.

Stem cells

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.

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.

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.

Inflammatory mediators

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.

Imbalances between MMPs and their inhibitors have been implicated in the underlying origin of tendinopathy.

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.

Implications for treatment

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.

MMP inhibitors have the potential to prevent ongoing tendon degeneration.

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.

Therefore, new agents that block either inflammatory mediators or MMPs may be effective in treatment of tendinosis.

Bottom line

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.
Research also indicates important interactions occur among load, inflammatory mediator expression, and MMP expression at the microscopic level.
Future studies involving the role of mechanical load may suggest ways to modulate the loading environment to stimulate tissue repair.
MMP inhibitors may have the potential to prevent ongoing tendon degeneration.

Additional resources

Treating tendinopathy with PRP
Tendinopathy treatment tips

AAOS Now
May 2011 Issue
Reference

Thanks,

JTM, MD

Knuckle Cracking and Hand Osteoarthritis

2011-05-03T07:50:00.000-04:00

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.

From Journal of the American Board of Family Medicine

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.

The authors 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.

Results: 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%; P = .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.

Conclusions: A history of habitual KC—including the total duration and total cumulative exposure—does not seem to be a risk factor for hand OA.

Introduction

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.
The behavior can become habitual because of immediate joint tension release and increased joint range of motion.

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.

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.

The amount of force required to crack a knuckle has been shown in vitro studies to exceed the energy threshold that can lead to articular cartilage damage.

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. 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.

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.

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.

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.

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.

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.

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.

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.

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.

Reference: Translated from Orthopedics to English for better patient understanding by JTM

Thanks,

JTM, MD

PRP does not improve rotator cuff healing

2011-04-21T17:05:00.000-04:00

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.

Two separate randomized trials show no benefit to using PRP fibrin matrix

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.

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.

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.

Fig. 1 A, A platelet-rich fibrin matrix is a flat, circular membrane of autologous suturable fibrin that must be used within 30 minutes. B, An intraoperative arthroscopic image of the platelet-rich fibrin matrix interposed between rotator cuff and bone. Courtesy of Roberto Castricini, MD

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 (Table 1). 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.

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.

Specialty Day support

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. The effect of platelet-rich fibrin matrix on rotator cuff tendon healing: A prospective randomized clinical study.

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.

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.

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.

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.

Additional Resources:
The Effect of Platelet-Rich Fibrin Matrix on Rotator Cuff Tendon Healing
Specialized Blood Plasma Treatment Does Not Improve Rotator Cuff Healing, Study Finds

Bottom Line

Two separate randomized studies found no significant benefit to using PRFM to improve healing after rotator cuff repair.
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.
More research is needed to uncover the ways that PRFM reacts with tendons, ligaments, and bones.

Reference: AAOS Now April 2011 Issue
http://www.aaos.org/news/aaosnow/apr11/clinical4.asp

Thanks,

JTM, MD

Complications of Treatment

2011-03-12T18:26:00.000-05:00

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 here to download a printable version of that document which is also posted on my website.

Thanks,

JTM, MD

Frozen Shoulder = Adhesive Capsulitis: The Stiff Shoulder

2011-02-03T15:12:00.000-05:00

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 that may be present for a while before patients even notice the loss of motion or the pain that accompanies this condition.

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.

Anatomy

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).

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.

To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

The shoulder capsule surrounds the shoulder joint and rotator cuff tendons.

Description

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:

Freezing

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.

Frozen

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.

Thawing

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.

In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.

Cause

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.

Diabetes. Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.

Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.

Immobilization. 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.

Symptoms

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.

Doctor Examination

Physical Examination

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.

Imaging Tests

Other tests that may help us rule out other causes of stiffness and pain include:

X-rays. Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in your shoulder, such as arthritis.

Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of problems with soft tissues, such as a torn rotator cuff.

Treatment

Frozen shoulder generally gets better over time, although it may take up to 3 years.

The focus of treatment is to control pain and restore motion and strength through physical therapy.

Nonsurgical Treatment

More than 90% of patients improve with relatively simple treatments to control pain and restore motion.

Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.

Steroid injections. 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.

Physical therapy. 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..

I advise patients to stretch frequently throughout the day.
5 minutes of stretching 5 times a day.
You should feel some stretching but it should not be painful.
You cannot do all of the exercises in 5 minutes 5 times a day, but patients can do some stretching in that time.

Below are examples of some of the exercises that might be recommended.

External rotation — passive stretch. 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.

External Rotation - Passive Stretch

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Forward flexion — supine position. 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.

Forward Flexion - Supine Position

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Crossover arm stretch. 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.

Crossover Arm Stretch

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Surgical Treatment

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.

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.

Manipulation under anesthesia. 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.
I generally do not advise this as there is risk of fracture and rotator cuff tear.

Shoulder arthroscopy. 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.

In many cases, manipulation and arthroscopy are used in combination to obtain maximum results. Most patients have very good outcomes with these procedures.

This is my preferred treatment if any procedure for frozen shoulder is advised.

These photos taken through an arthroscope show a normal shoulder joint lining (left) and an inflamed joint lining damaged by frozen shoulder.

Recovery. 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.

Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy.

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.

Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present.

From my web site.

Reference

Thanks,

JTM, MD

Biceps Tendon Tear at the Elbow

2011-02-02T11:57:00.001-05:00

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.

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.

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.

Anatomy

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.

Description

Biceps tendon tears can be either partial or complete.

Partial tears. These tears do not completely sever the tendon.

Complete tears. A complete tear will split the tendon into two pieces.

The biceps muscle helps you bend and rotate your arm. It attaches at the elbow to the radius bone on a small bump called the radial tuberosity.

A complete tear of the distal biceps tendon. The tendon is detached from the bone.

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.

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).

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.

Cause

The main cause of a distal biceps tendon tear is a sudden injury. These tears are rarely associated with other medical conditions.

Injury

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.

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.

Risk Factors

Men, age 30 years or older, are most likely to tear the distal biceps tendon.

Additional risk factors for distal biceps tendon tear include:
Smoking. Nicotine use can affect nutrition in the tendon.
Corticosteroid medications. Using corticosteroids has been linked to increased muscle and tendon weakness.

Symptoms

A distal biceps tendon tear can cause the muscle to ball up near the shoulder. Bruising at the elbow is also common.

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:

Swelling in the front of the elbow
Visible bruising in the elbow and forearm
Weakness in bending of the elbow
Weakness in twisting the forearm (supination)
A bulge in the upper part of the arm created by the recoiled, shortened biceps muscle
A gap in the front of the elbow created by the absence of the tendon

Doctor Examination

Medical History and Physical Examination

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.

In addition to the examination, your doctor may recommend imaging tests to help confirm a diagnosis.

Imaging Tests

X-rays. 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.

Magnetic resonance imaging (MRI). These scans create better images of soft tissues. They can show both partial and complete tears.

Treatment

Nonsurgical Treatment

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.

Patients must weigh the decision to proceed with nonsurgical treatment carefully, because restoring arm function with later surgery may not be possible.
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.
While other options are available for patients requesting late surgical treatment for this injury, they are more complicated and generally less successful.

Surgical Treatment

Procedure. 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.

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.
Be sure to carefully discuss the options available with your doctor.

X-rays showing metal implants called suture anchors that have been used to secure the biceps tendon to the bone.

Complications. Surgical complications are generally rare and temporary. They occur in about 6% to 9% of patients.

Numbness and/or weakness in the forearm can occur and usually goes away.
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.
Rerupture after full healing of the repair is uncommon.

Rehabilitation. Right after surgery, your arm may be immobilized in a cast or splint.
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.
Resistance exercises, such as lightly contracting the biceps or using elastic bands, may be gradually added to your rehabilitation plan.
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.
Light work activities can begin soon after surgery. But heavy lifting and vigorous activity should be avoided for several months.
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.
Surgical Outcome. Almost all patients have full range of motion at the final follow-up doctor visit.
After time, return to heavy activities and jobs involving manual labor is a reasonable expectation.

From the AAOS.org

Thanks,

JTM, MD

Bone Health from the AAOS

2011-01-04T08:19:00.000-05:00

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 Own the Bone.

Thanks,

JTM, MD

Skate, Slide and Glide Through Winter Injury-free

2010-12-23T09:53:00.000-05:00

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

STATISTICS:

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

AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS SAFETY TIPS:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reference

Thanks,

JTM, MD

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

2010-12-22T09:56:00.000-05:00

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

Read on from the AAOS...

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

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

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

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

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

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

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

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

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

Bottom line

The perfect repair.

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

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

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

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

Thanks,

JTM, MD

The Latest Study on Glucosamine and Chondroitin: Not good

2010-12-08T08:11:00.001-05:00

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.

Summary

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

Introduction

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

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

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

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

The Bottom Line

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

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

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

References

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

Thanks,

JTM, MD

Treating tendinopathy with PRP

2010-12-07T17:04:00.001-05:00

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

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

Letha Y. Griffin, MD, leads a focused roundtable

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Interesting but not yet ready for prime time.

Thanks,

JTM, MD

Battling a Biceps Injury

2010-12-07T14:54:00.000-05:00

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

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

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

allowing the elbow to bend (elbow flexion), and

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

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

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

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

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

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

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

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

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

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

pain and weakness in flexion and supination of the injured arm

People can help prevent biceps injuries by:

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

avoiding lifting heavy weights using a biceps curl; and

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

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

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

For more information on the distal biceps tendon click here.

For an interview about distal biceps ruptures, click here.

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

More elbow tendon stuff here.

Thanks,

JTM, MD

Lucky Break: Quit Smoking after Fracture Surgery for Better Healing

2010-12-07T12:56:00.000-05:00

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

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

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

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

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

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

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

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

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

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

causing wound site infections.

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

Stop smoking.

Thanks,

JTM, MD

Treatment Trends for Biceps Injuries

2010-12-07T11:56:00.000-05:00

From AAOS.org.

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

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

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

Statistics:

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

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

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

Trends noted:

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

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

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

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

Rest;

anti-inflammatory drugs;

activity modification; and

physical therapy.

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

Symptoms:

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

Sudden, sharp pain in the upper arm

Audible popping or snapping in the shoulder or elbow

Cramping of the biceps muscle with strenuous use of the arm

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

Pain or tenderness at the shoulder and the elbow

Weakness in the shoulder and the elbow

Difficulty turning the palm of the hand up or down

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

More on the shoulder biceps tendon here.

Thanks

JTM, MD

Osteolysis of the Distal Clavicle

2010-12-02T17:03:00.000-05:00

What is the anatomy of acromioclavicular (AC) joint?

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

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

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

What is osteolysis of the distal clavicle?

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

What can cause AC joint osteolysis?

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

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

What does osteolysis of the distal clavicle feel like?

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

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

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

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

What is the treatment for osteolysis of the distal clavicle?

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

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

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

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

Can osteolysis of the distal clavicle be prevented?

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

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

Thanks,

JTM, MD

Symptomatic Progression of Asymptomatic Rotator Cuff Tears

2010-11-30T13:01:00.000-05:00

A recent study from the major orthopedic journal investigated the progression of painful rotator cuff tendon tears. I have excerpted a portion of the article below. This is a question that I am frequently asked by patients.

The study demonstrates that a substantial proportion of subjectswith asymptomatic rotator cuff tears become symptomatic aftera short-term follow-up period. Pain development in asymptomaticrotator cuff tears is associated with tear size progression.Collectively, the subjects who developed new shoulder pain showedsignificant tear size increases compared with baseline measurements,whereas those who remained asymptomatic had no significant changein tear size. Likewise, the rate of tear progression, as definedin this study, for the symptomatic group (23%) was significantlygreater than the rate for the asymptomatic group (4%). Tearprogression manifested as both enlargement of full-thicknesstears as well as conversion of partial-thickness to full-thicknesstendon defects. The lack of tear progression seen in the majorityof newly symptomatic tears, however, suggests that factors otherthan tear progression likely play a role in the evolution ofsymptoms for these patients. Given the high prevalence of asymptomaticrotator cuff disease, especially in individuals older than sixtyyears or in patients with a painful rotator cuff tear in thecontralateral shoulder, these findings are clinically relevant.The onset of shoulder pain in a patient with a known preexistingasymptomatic tear may indicate an increase in tear size, whichwould potentially affect the clinical management of these patients.

Compared with the group of subjects who remained asymptomatic,the subjects who developed pain were found to have significantlylarger tears at the time of enrollment. This suggests that theabsolute size of an asymptomatic tear may be a predictor offuture pain development. Previously, we reported the averagesize of symptomatic tears to be 30% larger than that of asymptomatictears. There may be a cuff tear size threshold that predisposesa subject to future pain development, irrespective of tear progression.Future studies are necessary to define the relationship of absolutetear size and tear progression with pain development in theshoulders with an asymptomatic rotator cuff tear. In addition,a significant difference in predilection toward hand dominancewas seen between the shoulders that developed pain (56% wereon the dominant side) and those that remained asymptomatic (26%were on the dominant side). This may be explained by the findingthat the dominant-side shoulders initially had larger tearsthan the nondominant shoulders. It is also possible that handdominance, irrespective of tear size, predisposes a shoulderwith an asymptomatic tear to develop symptoms.

This study demonstrates that shoulder function deterioratesas asymptomatic rotator cuff tears became painful. All measures of active range of motion of the shoulder, withthe exception of external rotation at 90° of abduction,decreased significantly after pain development. Interestingly,the subjects who remained asymptomatic also showed a decreasein forward elevation and internal rotation in extension. Thesefindings suggest that progressive loss of range of motion ofthe shoulder may be a consequence of the presence of a rotatorcuff tear, regardless of the presence of symptoms. The declinesin active range of motion seen in this study were small at thisshort-term time point and would be difficult to appreciate clinically.Furthermore, the differences seen between symptomatic and asymptomaticshoulders were not clinically important. Further studies areneeded to determine if this loss of shoulder motion progressesover time and if specific strategies can prevent or correctthe functional changes in this patient cohort.

External rotation strength of the shoulder was not significantlyaffected by new pain development. This can be explained by thefact that the tears included in this study were relatively smallin size. These tears primarily involved the supraspinatus tendon,whereas the majority of the infraspinatus tendon was preserved,thus minimizing external rotation weakness. Furthermore, degenerativechanges within the rotator cuff musculature were minimal, likelypreserving cuff strength. It is possible that scapular planeabduction strength may have been a more sensitive test for thedetection of disease progression in these subjects as this testis more sensitive to detect supraspinatus tears and has beenpreviously correlated to the size of asymptomatic rotator cufftears.

This study demonstrates that pain development in asymptomaticrotator cuff tears is not associated with progression of fattydegeneration of the rotator cuff muscles. This may be explainedby the relatively short time period (one year) between the evaluationtime points and the relatively small size of the tears includedin this study. Nonetheless, it is notable that progressive fattydegeneration is not associated with pain development or tearenlargement in previously asymptomatic rotator cuff tears.

In summary, the risk of symptom progression for asymptomaticrotator cuff tears after a short-term follow-up interval issubstantial. In this study, shoulders that developed pain hadsignificantly larger tears at baseline and demonstrated a higherrate of tear progression than those that remained asymptomatic.Shoulder function and active range of motion deteriorated withsymptom onset; however, no significant changes were found inexternal rotation strength or fatty degeneration of the rotatorcuff muscles after pain development. There was an increase ofcompensatory scapulothoracic motion during early shoulder abductionafter pain development; however, no increase in proximal humeralmigration was seen.

The message here is that tears that are not treated and repaired will progress and get bigger over time. Bigger tears get worse faster and are more likely to cause pain and impairment. Patients with rotator cuff tears will often have to use their upper back muscles to fully lift the shoulder which is why we examine the neck and upper back (thoracic spine) for shoulder examinations. Further study is needed to follow these tears over longer periods of time.

Reference: The Journal of Bone and Joint Surgery (American). 2010;92:2623-2633.

Thanks,

JTM, MD

Lateral Epicondylitis Tennis Eblow

2010-11-28T14:23:00.006-05:00

Lateral epicondylitis, or tennis elbow, is a commonly encountered problem in orthopedic practice.

Problem
Lateral epicondylitis (tennis elbow) is an overuse injury involving the extensor muscles that originate on the (outer elbow) lateral epicondylar region of the distal humerus. It is more properly termed a tendinosis that specifically involves the origin of the extensor carpi radialis brevis muscle (one of the tendons that extends the wrist.

Frequency
Lateral epicondylitis (tennis elbow) has been demonstrated to occur in up to 50% of tennis players. However, this condition is not limited to tennis players and has been reported to be the result of overuse from many activities. Lateral epicondylitis is extremely common in today's active society.

Causes
Any activity involving wrist extension and/or supination (turning the forearm in a clockwise direction as if turning a screwdriver) can be associated with overuse of the muscles originating at the lateral epicondyle (outer elbow). Tennis has been the activity most commonly associated with the disorder. The risk of overuse injury is increased 2-3 times in players with more than 2 hours of play per week and 2-4 times in players older than 40 years. Several risk factors have been identified, including improper technique, size of racquet handle, and racquet weight.

I see more work related elbow pain. For work-related lateral epicondylitis, a systematic review identified 3 risk factors: handling tools heavier than 1 kg, handling loads heavier than 20 kg at least 10 times per day, and repetitive movements for more than 2 hours per day. The review also found that low job control and low social support were psychosocial factors associated with lateral epicondylitis.

What happens to the tendon
The cause of tennis elbow is a microscopic tearing with formation of reparative tissue (ie, angiofibroblastic hyperplasia) in the origin of the extensor carpi radialis brevis (ECRB) muscle. This is one of the wrist extensors. This microtearing and repair response can lead to macroscopic tearing and structural failure of the origin of the ECRB muscle.
Concomitant intra-articular lesions (eg, loose bodies, synovitis, bone spurs, early arthritic lesions) have been visualized during elbow arthroscopy in patients with lateral epicondylitis. However, while concomitant intra-articular pathology has been noted, this process is currently considered an extra-articular process.

Presentation
Patients present complaining of lateral elbow and forearm pain exacerbated by use. The typical patient is a man or woman aged 35-55 years who either is a recreational athlete or one who engages in rigorous daily activities.

Upon examination, the patient has a point of maximal tenderness just distal (5-10 mm) to the lateral epicondyle in the area of the extensor carpi radialis brevis (ECRB) muscle. Wrist extension or supination (but not flexion or pronation) against resistance with the elbow extended should provoke the patient's symptoms. Another helpful test is the chair raise test. The patient stands behind their chair and attempts to raise it by putting their hands on the top of the chair back and lifting. In patients with lateral epicondylitis, pain results over the lateral elbow.

Indications
Approximately 90-95% of patients with lateral epicondylitis (tennis elbow) respond to conservative measures and do not require surgical intervention. Patients whose condition is unresponsive to 6 months of conservative therapy (including corticosteroid injections) are candidates for surgery.

Relevant Anatomy
The extensor carpi radialis brevis (ECRB) muscle arises from the lateral epicondyle. The ECRB muscle lies deep to the extensor carpi radialis longus (ECRL) muscle and superficial to the joint capsule. The annular and collateral ligaments are located beneath and just distal to the origin of the ECRB muscle.

Contraindications
No absolute contraindications to lateral epicondylitis (tennis elbow) surgery exist. It is advisable to offer surgery only after patients have failed 3-6 months of nonoperative modalities, such as steroid injections, splinting, and occupational therapy. Relative contraindications include any comorbidities that would place the patient at a more serious level of surgical risk.

Workup

Imaging Studies

Radiographs (x-rays) can be helpful in ruling out other disorders or concomitant intra-articular pathology (eg, osteochondral loose body, posterior osteophytes, bone spurs). Calcification in the degenerative tissue of the extensor carpi radialis brevis (ECRB) muscle origin can be seen in chronic cases.
Magnetic resonance imaging can help confirm the presence of degenerative tissue in the ECRB muscle origin and can help diagnose concomitant pathology. A guideline from the American College of Radiology (ACR) recommends MRI as the most appropriate imaging study for patients with suspected chronic epicondylitis when radiographs are nondiagnostic.
I usually do not require an MRI to diagnose and treat tennis elbow.

Other Tests

If the clinical examination indicates a possible neural etiology for the patient's symptoms, electromyography can be helpful in excluding posterior interosseous nerve compression syndrome as the diagnosis.

Diagnostic Procedures

Anesthetic injections into the origin of the extensor carpi radialis brevis (ECRB) muscle can help confirm the diagnosis, as the patient should experience relief from symptoms.

Histologic Findings

Despite the misnomer of lateral epicondylitis (tennis elbow), the histology of lesions shows neither acute nor chronic inflammatory cell infiltrate. Lesions are characterized by fibroblastic invasion with neovascularization. However, most other studies indicate degenerative changes.

Staging
There are 4 progressive stages:

Stage 1 - Inflammatory changes that are reversible
Stage 2 - Nonreversible pathologic changes to origin of the extensor carpi radialis brevis (ECRB) muscle
Stage 3 - Rupture of ECRB muscle origin
Stage 4 - Secondary changes such as fibrosis or calcification

Treatment

Medical Therapy

Nonsurgical treatment is the mainstay of care for patients with lateral epicondylitis (tennis elbow). The goal of initial treatment is cessation of the offending activity. Rest, use of a counterforce brace (a tennis elbow band), and nonsteroidal anti-inflammatory drugs (NSAIDs) often provide relief of symptoms. Often, wrist splinting is necessary.

I find wrist immobilizers to be more effective than tennis elbow bands in the early phases of painful tennis elbow. The wrist splint puts the injured tendon at rest allowing the inflammation to calm down thereby relieving pain.

Other researchers found the tennis elbow band to be more effective. One study compared 3 common types of braces for their effect on grip strength in patients with lateral epicondylosis. In a randomized, controlled study of 52 patients, maximum and pain-free grip strength were assessed with the patient wearing an elbow strap orthosis, an elbow sleeve orthosis, a wrist splint, or a placebo orthosis. Use of the elbow strap and sleeve orthoses resulted in an immediate and equivalent increase in pain-free grip strength; consequently, the researchers suggest that either of these types of orthosis may be used. The wrist splint provided no immediate improvement in either pain-free or maximum grip strength.

Both corticosteroid and autologous blood injections have been shown to be effective. Corticosteroid injections at the lateral epicondyle have been shown to significantly decrease pain scores in the early post-injection period.

When the patient is free of pain through a full range of motion, begin strengthening therapy in a very slow and progressive way. When the patient regains strength and nears resumption of activity, place the emphasis on preventing future irritation (eg, correct technique or address equipment concerns in athletes who participate in racquet sports, modify jobs or activities in patients who are not athletes).

Therapy in patients who are having considerable pain from inflammation seems to be counter productive as it often aggravates the pain. Controlling inflammation and reducing pain enables patients to do more productive physical therapy.

The use of shockwave therapy raised initial excitement. However, 2 prospective, randomized, blinded trials showed no benefit of this intervention over placebo.

Surgical Therapy
A myriad of surgical procedures has been described for the treatment of lateral epicondylitis (tennis elbow). However, most surgical procedures involve debridement of the diseased tissue of the extensor carpi radialis brevis (ECRB) muscle with decortication of the lateral epicondyle. This procedure has been performed through open, percutaneous, and arthroscopic approaches.

Preoperative Details
Note the length of time of the patient's symptoms. Also note the conservative therapeutic course that has been implemented, including any corticosteroid injections. Consider the patient's workers' compensation status, as patients with workers' compensation claims may not respond as well to intervention.

A full evaluation should be performed on patients with lateral epicondylitis (tennis elbow) so that any other associated conditions can be detected.

Intraoperative Details
In the classic open-release procedure for lateral epicondylitis (tennis elbow), the patient is positioned supine.A 3-cm longitudinal incision is made over the lateral epicondyle. An incision is made through the extensor aponeurosis (outer elbow). The extensor carpi radialis brevis (ECRL) muscle is retracted medially, revealing the degenerative origin of the ECRB. All pathologic tissue is excised. The lateral epicondyle is decorticated with an osteotome, burr or by drill holes. The ECRL is sewn to the extensor aponeurosis in an attempt to repair the defect.

Lateral epicondylitis. Incision for open debridement of lateral epicondyle. Lateral epicondyle is circled.

Revision debridement for lateral epicondylitis. The fascia covering the origin of the extensor carpi radialis brevis muscle and the extensor carpi radialis longus muscle is fibrotic.

The extensor origin exposed

Lateral epicondylitis. Osteotome positioned over lateral epicondyle.

Postoperative Details

Surgical treatment of lateral epicondylitis (tennis elbow) is an outpatient surgical procedure. If the open approach is used, the elbow is usually protected initially with a splint or brace at 90°.

Follow-up
Early motion in a brace may be initiated at 2-3 days after surgical treatment of lateral epicondylitis (tennis elbow), with strengthening exercises usually started by 3 weeks, depending on the patient's symptoms. Return to racquet sports can be expected by 4-6 months. Depending on the specific job requirements, patients can return to work in 6-12 weeks, although job modification or persistent use of a counterforce brace during work activities may be necessary.

I usually advise patients to wear the tennis elbow band for up to 6 months post op for heavy or demanding physical tasks to protect the healing tendon.

Complications

One of the most concerning complications of aggressive surgical debridement for lateral epicondylitis (tennis elbow) is lateral elbow instability. The proximity of the lateral collateral ligaments and the annular ligament makes them susceptible to injury. Other complications include recurrence or incomplete relief of pain.

Outcome and Prognosis
Surgical treatment of lateral epicondylitis (tennis elbow) has yielded predictably favorable results, with approximately 85% of patients reporting complete pain relief. Some patients may have persistent symptoms despite surgical treatment, and these patients may benefit from a more aggressive debridement.

Reference

Patients can link to my web site tennis elbow information here. You can download a booklet on lateral epicondylitis here and a booklet on medial epicondylitis here.

Thanks,

JTM, MD

Tai Chi Exercise Reduces Knee Osteoarthritis Pain in the Elderly

2010-11-28T13:19:00.002-05:00

Researchers from Tufts University School of Medicine have determined that patients over 65 years of age with knee osteoarthritis (OA) who engage in regular Tai Chi exercise improve physical function and experience less pain. Tai Chi (Chuan) is a traditional style of Chinese martial arts that features slow, rhythmic movements to induce mental relaxation and enhance balance, strength, flexibility, and self-efficacy.

The elderly population is at most risk for developing knee OA, which results in pain, functional limitations or disabilities and a reduced quality of life. According to the Centers for Disease Control and Prevention (CDC) there are 4.3 million U.S. adults over age 60 diagnosed with knee OA, a common form of arthritis that causes wearing of joint cartilage. A recent CDC report further explains that half of American adults may develop symptoms of OA in at least one knee by age 85.

For this study, 40 patients from the greater Boston area with confirmed knee OA who were in otherwise good health. The mean age of participants was 65 years with a mean body mass index of 30.0 kg/m². Patients were randomly selected and 20 were asked to participate in 60-minute Yang style Tai Chi sessions twice weekly for 12 weeks. Each session included: a 10-minute self-massage and a review of Tai Chi principles; 30 minutes of Tai Chi movement; 10 minutes of breathing technique; and 10 minutes of relaxation.

Tai Chi is a mind-body approach that appears to be an applicable treatment for older adults with knee OA. Physical components of Tai Chi are consistent with current exercise recommendations for OA, which include range of motion, flexibility, muscle conditioning, and aerobic work out. Researchers believe the mental feature of Tai Chi addresses negative effects of chronic pain by promoting psychological well being, life satisfaction, and perceptions of health.

The remaining 20 participants assigned to the control group attended two 60-minute class sessions per week for 12 weeks. Each control session included 40 minutes of instruction covering OA as a disease, diet and nutrition, therapies to treat OA, or physical and mental health education. The final 20 minutes consisted of stretching exercises involving the upper body, trunk, and lower body, with each stretch being held for 10–15 seconds.

At the end of the 12-week period, patients practicing Tai Chi exhibited a significant decrease in knee pain compared with those in the control group. Researchers noted a reduction in pain between the Tai Chi and control group. Researchers also observed improved physical function, self-efficacy, depression, and health status for knee OA in subjects in the Tai Chi group.

Wow. Exercise (including Tai Chi in this study and Yoga as well) is good for knee artrhritis. Who knew? Actually, my patients knew this since I have been an advocate of these kind of exercise programs for many years.

Of course, all of my knee arthritis patients will be required to demonstrate the yoga pose below after completing their treatment for their knee arthritis.

References

Article: "Tai Chi Is Effective in Treating Knee Osteoarthritis: A Randomized Controlled Trial." Chenchen Wang, Christopher H. Schmid, Patricia L. Hibberd, Robert Kalish, Ronenn Roubenoff, Ramel Rones, and Timothy McAlindon. Arthritis Care & Research; Published Online: October 29, 2009 (DOI:10.1002/art.24832); Print Issue Date: November 2009.

Thanks,

JTM, MD

SLAP Lesions

2010-11-28T12:05:00.050-05:00

Reference, adapted, with permission, from one of the best shoulder sites on the web, www.shoulderdoc.co.uk.

What is a SLAP lesion?

The shoulder is a ball-and-socket type of joint and is anatomically referred to as the glenohumeral joint, describing the two bony structures involved. The socket is the glenoid cavity, a cup-shaped piece of bone that juts out from a corner of the shoulder blade (scapula). The rim of the glenoid is formed by cartilage called the labrum. The ball that fits into the socket is the head (upper part) of the humerus (arm bone).

The upper (superior) part of the labrum anchors one of the two tendons of the biceps muscle. The feature that makes SLAP possible is the way the upper biceps tendon hooks over the head of the humerus. If the arm is forcefully bent inward and twists at the shoulder, the humeral head acts as a lever and tears the biceps tendon and labrum glenoid bone in a front-to-back (anterior-posterior) direction. And that is how the name SLAP is derived - Superior Labrum Anterior-Posterior or, in plain English, Upper Rim Front-Back. cartilage from the

SLAP area and SLAP Lesion - pull-off of the Biceps origin (superior labrum) from the glenoid.

Causes and Risk Factors

Often an initial forceful movement of the labrum attached to the biceps tendon to be torn away from the bone (glenoid). This may be associated with a dislocation of the joint, but commonly occurs in athletes and workers with a pull on the arm, weightlifting, throwing injury or tackle. Laborers can tear the labrum with a slip and fall while holding on a railing with the injured arm. If the initial condition does not heal properly, pain will result and worsen over time.

The typical symptoms are pain at the top of the shoulder, clicking and pain with overhead activities. These may be confused with AC Joint problems , but athletes with SLAP tears have pain with eccentric biceps loading (such as going down in a bench press). AC Joint pain is usually felt when pressing out at the end of a shoulder or bench press.

Risk Factors: Overhead and contact sports pose a greater risk of labral tears (SLAP lesions). Workers performing heavy lifting or pulling tasks are also at risk. Sudden traction injuries to the arm are common causes of SLAP lesions.

Types of SLAP Tears - Depending on the type and severity of injury, the labrum will tear in different ways and degrees. These are classified as a guide to treatment.

If you have been diagnosed with a SLAP tear, your surgeon may have called it a 'Type 1 or 2 or 3, etc'. SLAP tears have been classified according to their severity of tear. Please note that it does not mean that the outcome of surgery is worse, it just gives us surgeons a guide to management and a form of communication. The common types are types 1 to 4. There are other types, but these are rare.

SLAP Type 1

This is a partial tear and degeneration to the superior labrum, where the edges are rough and fray along the free margin, but the labrum is not completely detached.

Treatment is usually to 'debride' (clean) the edges.

SLAP Type 2

Type 2 is the commonest type of SLAP tear. The superior labrum is completely torn off the glenoid, due to an injury. This type leaves a gap between the articular cartilage and the labral attachment to the bone. Type 2 SLAP tears can be further subdivided into (a) anterior (b) posterior, and (c) combined anterior-posterior lesions.

Treatment is reattachment of the labrum (SLAP repair). This is done arthroscopically using suture anchors. Recent data suggests that type 2 SLAP lesions do very well with a debridement and biceps tenodesis rather than repair of the labrum. Tenodesis seems to be associated with a lower rate of complications and a faster return to work. Many shoulder surgeons limit SLAP repairs to overhead throwing athletes.

SLAP Type 3

A Type 3 tear is a 'bucket-handle' tear of the labrum, where the torn labrum hangs into the joint and causes symptoms of 'locking' and 'popping' or 'clunking'.

Treatment usually involves removal of the 'bucket-handle' segment and then repair of any remaining detached, unstable labrum (SLAP repair). This is done arthroscopically using suture anchors.

Biceps tenodesis seems to be associated with a lower rate of complications and a faster return to work. Many shoulder surgeons limit SLAP repairs to overhead throwing athletes.

SLAP Type 4

The Type 4 SLAP tear is one where the tear of the labrum extends into the long head of biceps tendon. Treatment is reattachment of the labrum (SLAP repair) and repair of the biceps tear, or a biceps tenodesis. This is done arthroscopically using suture anchors.

Prevention of SLAP lesions

Strong shoulder muscles remain the best defense against shoulder injuries. Exercises that build up these muscles around the shoulder should be done. Adequate warm-up before activity and avoidance of high-contact sports will help prevent of an instability-causing injury.

Treatment

Painkillers and anti-inflammatories - help control the pain.

Physical therapy can be helpful is some cases of SLAP lesions and should be considered if shoulder motion is limited or if there is weakness of the shoulder related to the initial injury.

Surgery may be recommended if an patient wants to continue their work, sports and training - SLAP lesions are sometimes repaired by arthroscopically through 2 or 3 small incisions. Some SLAP lesions can be simply debrided and cleaned, while most need repairing depending on the severity of the lesion. The associated lesions are also treated such as labrum and ligament lesions with instability.

You can see an animation of a SLAP repair on my website here. Go to the shoulder section and select SLAP repair.

Try this link as well for a SLAP repair.

Recent data and reports suggests that the only patients who should have their SLAP lesion repaired should be overhead throwing athletes. Other with SLAP lesions seem to have superior outcomes with an arthroscopic debridement and tenodesis of biceps tendon.

Biceps Tenodesis

In this procedure the long head of the biceps tendon is detached from it's attachment in the shoulder and reattached to the humerus bone just below the shoulder. This procedure is more complex than a tenotomy, but avoids the risks of biceps discomfort (rare), and a 'popeye' appearance of the biceps muscle. Weakness is usually not a problem after biceps tenotomy.

Tenodesis, rather than tenotomy, may be preferable for more active, younger, thinner patients and those concerned about the appearance of the arm after surgery. Using modern fixation screws the repair is strong enough to move the arm early after surgery, without immobilization.

The Procedure:

1. The long head of the biceps tendon is released via the arthroscope:

arthroscopic scissors inserted via small puncture hole in skin and cutting the long head of biceps (arthroscopic view on the right).

2. A small incision (5cm) is made over the front of the shoulder and the tendon retrieved through this hole:

3. The tendon is fixed back into the bone of the humerus with a special interference screw:

Information before your surgery

You must not eat or drink anything after midnight the day before your surgery. When you wake up following the procedure you will be wearing a sling with a body belt. The sling should be worn for a few days to up to 6 weeks depending on the procedure performed and the time required for healing.

You will probably not be in hospital overnight after your operation, and should be able to go home about 4 hours after the surgery. Your may be given some exercises on your post operative discharge instructions and instructions on when to begin them.

At your first post operative visit in the office, I will review the procedure performed and your restrictions. You should also prepare to see the physical therapist in the office who will teach you the appropriate exercises. You will need physiotherapy after the surgery and should return to your own therapist.

Pain

A nerve block is usually used during the surgery. This means that immediately after the operation the shoulder and arm often feel completely numb. This may last for a few hours. After this the shoulder may well be sore and you will be given painkillers. These can be continued after you are discharged home. Ice packs or a cold compression wrap may also help reduce pain. Wrap crushed ice or frozen peas in a damp, cold cloth and place on the shoulder for up to 15 minutes. Ensuring you cover the wound site with a piece of gauze and tape to keep the area dry.

Wounds

This arthroscopic operation is usually done through two or three 5mm puncture wounds. There may be stitches under the skin and there may be paper strips over the wounds. These can be kept dry until healed. In some cases, I will give you permission to shower and get the wounds wet after surgery. It depends on the size of the incision.

Sleeping

For the first 3 - 6 weeks your sling must be worn in bed. Sleeping can be uncomfortable if you try and lie on the operated arm. We recommend that you lie on your back or on the opposite side, as you prefer.

Sleeping in a reclined position in a reclining chair or on a couch surrounded by pillows is usually the most comfortable position.

Ordinary pillows can be used to give you comfort and support. If you are lying on your side one pillow slightly folded under your neck gives enough support for most people. A pillow folded in half supports the arm in front and a pillow tucked along your back helps to prevent you rolling onto the operated shoulder during the night. If you are lying on your back, tie a pillow tightly in the middle (a "butterfly pillow") or use a folded pillow to support your neck. Place a folded pillow under the elbow of the operated arm to support that.

Follow up appointments

An appointment will be made for you to see the me in the office on the first office day after surgery.

Daily activities

After a SLAP repair, for the first three weeks all activities of daily living for example feeding, dressing, cooking etc must be carried out using your un-operated arm. If appropriate an physical therapist will be available to give you advice on how to do this. Activities may also be limited for as long as 6 weeks after a repair. My patients usually see the therapist at the first post op visit the day after surgery.

If you had a SLAP debridement and biceps tenodesis (reattachment of the biceps to the upper humerus), I usually allow patients to move the shoulder immediately after surgery. You may not use the operative arm / hand to lift or pull anything since this may result in a rupture of the biceps tenodesis. Moving the shoulder is permitted.

If you had a SLAP debridement and biceps tenotomy (biceps cut and released and not repaired), you may use the arm as tolerated without restrictions immediately after surgery. You activities are limited by you pain.

Your physical therapist and surgeon will advise you when it is safe to resume your leisure activities. This will vary according to your sport and level, as well as the period required to retrain your shoulder muscles with physical therapy.

Driving

You may not be able to drive for a minimum of 4 weeks. Your surgeon will confirm when you may begin.

Return to work

This will depend upon whether the SLAP lesion was repaired, which requires additional healing time or whether a SLAP debridement and biceps tenodesis was performed.

In my experience, patients may return to work sooner if they have had a debridement and tenodesis or tenotomy than those who have had a SLAP repair. Patients having a SLAP repair seem to develop more stiffness and more post op discomfort than those having tenodesis of tenotomy.

You will need to discuss this with your surgeon.

Reference, adapted from one of the best shoulder sites on the web, www.shoulderdoc.co.uk.

Thanks for the reminder and permission, Prof. Funk.

Thanks,

JTM, MD

Nutrient-Dense Diet May Reduce Risk for Low-Trauma Fracture

2010-11-28T10:03:00.000-05:00

Since the recent post have been about calcium and vitamin D as it relates to bone health, I thought one more related article could not hurt.

A nutrient-dense diet high in vegetables, fruit, and whole grains may reduce the risk for low-trauma fracture, particularly in older women, according to the results of a retrospective cohort study reported online November 10 in the American Journal of Clinical Nutrition.

In 2005, 2 million fractures occurred in the United States, which were associated with 17 billion in direct costs, and these figures are expected to increase by ≥50% over 20 years. Fractures also led to long-term disability, decreased health-related quality of life, and increased mortality. Identification and treatment of individuals with low bone mineral density (BMD) can reduce the burden of fracture, [but] alternative strategies for population health are necessary because many individuals who fracture do not have a low BMD.

Using a randomly selected, population-based cohort enrolled in the Canadian Multicentre Osteoporosis Study, the investigators aimed to determine the association between dietary patterns and incident fracture and to evaluate whether body mass index (BMI), BMD, or falls affected this relationship. In year 2 of the study (1997-1999), they used self-administered food frequency questionnaires to evaluate dietary patterns. The main study endpoint was low-trauma fracture occurring before the 10th annual follow-up in 2005 to 2007.

Factor analysis revealed 2 dietary patterns: nutrient dense, which emphasized intake of fruit, vegetables, and whole grains; and energy dense, which had higher intake of soft drinks, potato chips, French fries, meats, and desserts.

In association with the nutrient-dense factor, the risk for fracture was reduced in both men overall women overall. No associations with fracture were identified for the energy-dense pattern.

Conclusion

A diet high in nutrient-dense foods (vegetables, fruits, whole grains) may reduce the risk of low-trauma fracture, especially among older women, the study authors conclude. Because older women are also at the highest risk of fracture, population measures to encourage increased intake of fruit, vegetables, and whole grains have the potential to lower the population burden of fracture, including hip fracture. Few recent studies have assessed dietary patterns related to fracture outcomes. The results here are complementary to those of studies that assessed the relation of specific foods and nutrients, because synergistic effects of food combinations might exist.

Reference

Am J Clin Nutr. Published online November 10, 2010. Abstract

So, I guess the message here is to eat your fruits and vegetables. I am off to search for more earth shattering information for the newsletter.

Thanks,

JTM, MD