News Category: General

Steroid injections can be used to diagnose and treat nerve compression in the wrist and foot. Carpal tunnel syndrome (CTS) can cause burning pain, numbness, and/or tingling in the thumb and first two fingers.

Pressure on the median nerve as it goes through the carpal tunnel is the underlying problem. The carpal tunnel is a space between the bones of the wrist and the retinaculum ligament across the wrist. There is usually enough room for the nerves to pass through this area undisturbed.

A similar problem called tarsal tunnel syndrome (TTS) can occur in the ankle and foot. Pressure on the tibial nerve can also cause ankle pain and pain, numbness, or tingling along the bottom of the foot.

Corticosteroid injection can bring relief from the symptoms. It is both a pain reliever and an antiinflammatory. Injections serve as a treatment and a diagnostic tool. If the wrist or ankle symptoms are eliminated by injection, then the problem was most likely nerve compression.

The authors review supplies needed for the procedure. They present surface anatomy to help the surgeon find the tunnel and locate the nerve. The patient’s position is important. Once the patient is placed in the best position, the skin is numbed and the injection is given.

Specific steps are included such as proper sterilization, angle of needle insertion, and proper length to advance the needle. Injection of the tendon can be avoided using proper patient positioning and stopping if there is any pain, numbness, or resistance.

If problems occur, the needle can be pulled back out and redirected. Patients should be told that their symptoms may get worse at first. This doesn’t last. It’s caused by the extra fluid of the steroid that has been pumped into the tunnel area.

This article was one of a dozen in a series describing the most commonly injected joints and bursae. Eight more of these procedural reviews will be presented in future publications of this journal.

Early diagnosis of rheumatoid arthritis (RA) is very important. Damage to the joints is occurring Even before symptoms start. Making the diagnosis and starting treatment early can help preserve function and prevent disability.

In this article, two rheumatologists (doctors specializing in RA) review the problems doctors face in making the diagnosis soon enough. They also discuss tests that are used to identify patients with RA.

The authors point out that the American College of Rheumatology’s (ACR) Criteria for the Classification of RA are outdated. Improved technology for lab testing and advanced imaging have made it possible to identify the disease sooner.

Studies show that patients with RA have the best results when the disease is treated within the first year of symptoms. Patients should be sent to a rheumatologist or arthritis clinic if they have any of the following symptoms:

In this report, the latest research findings for current drug therapies for rheumatoid arthritis (RA) are reviewed. Over the last 20 years, doctors have come to realize that RA must be treated early and aggressively.

New medications called disease-modifying antirheumatic drugs (DMARDs) have made it possible to halt the progression of this disease. Used in combination, joint damage can be prevented and even reversed. But significant side effects are possible. Patient must be monitored carefully.

Triple DMARD refers to the use of methotrexate (MTX), sulfasalazine (SSZ), and hydroxychloroquine. When combined together, results are much better than when used separately. Patients experience greater improvement in symptoms. Results are faster with this approach.

Studies are ongoing using different amounts and combinations of drugs. Doctors work with patients to find the most effective dosage to get the inflammatory process under control. High-dose DMARD may be needed to achieve this result. Then a maintenance dose is determined.

Some patients do not respond well to DMARDs. Other biologic agents are available and remain under study. These include tumor necrosis factors-alpha (TNF-a) antagonists and interleukin-1 receptor antagonist (IL-1RA).

Patients may recognize biologic agents by their names such as rituximab, etanercept, infliximab, adalimumab, anakinra, and abatacept. The goal is to find ways to stop the disease process at different places in the cycle. Researchers are trying to find drugs that work in both early and late disease.

When casts are applied to limbs for immobilization, a reaction occurs between the materials that produces heat – sometimes hot enough to cause damage to the skin below. While cast-related complications, such as burns, are not unusual, there isn’t much research available on how these may be prevented.

The authors of this study investigated the reasons for the injuries, despite the availability of new materials that were meant to reduce the risk. To do this, the researchers looked at the variables that can affect the production of heat. These included ambient temperature, temperature of the reactants, and the reactants themselves.

Earlier studies have shown that more layers (over eight), reusing dip water, and warmer dip water all can contribute to producing heat.

Because it would not be ethical to test cast temperatures on patients, the researchers devised a model with which they could measure the amount of heat produced by the casting material and process. They included several variables in the trial, such as the diameter and shape of the limbs, the thickness of the plaster application, the type of cast, the dip water temperature, or if placement of the cast on a pillow while the cast was setting or curing. With the plaster casts, the researchers applied six, 12, and 24 ply over three or four layers of cotton.

The results of the study showed that the external temperature of a plaster cast was on average, 2.7 degrees Celsius (plus or minus 1.9 degrees) cooler than the internal temperature. The researchers found that dip water temperature that was less than 24 degrees as more likely to prevent thermal damage, regardless of how thick the plaster cast was. They also found that the thinner the cast, the less important the dip water temperature as long as it was below 50 degrees.

A thicker plaster cast, of 24 ply, could cause significant burns if the dip water was at 50 degrees. The same finding occurred with 12-ply casts that were folded over on the end – effectively doubling the thickness.

Smaller limbs saw slightly higher temperatures (50.9 degrees, plus or minus 1 degree), while the standard size had a lower temperature of 50.5 degrees (plus or minus 1 degree) and the larger limbs a temperature of 49.9 degrees (plus or minus 1.7 degrees). The shape of the limb caused a difference: an L-shaped limb consistently produced higher temperatures than did the straight limbs (60.1 degrees and 52.1 degrees, respectively). When the researchers eased the curve with a slap of plaster and by reducing the number of wraps in the curve, the temperature dropped significantly.

When the researchers applied fiberglass over plaster, the temperature rose high enough to cause a burn, as did placing a limb with a 12-ply cast on a pillow; with the bottom part of the cast being quite a bit warmer than the top part.

Some interventions to decrease the temperature of the cast include applying ice packs between limb and pillow or avoid using the pillow if possible. The authors do not agree with the practice of applying isopropyl alcohol to the cast to decrease the temperature, as they found it only decreased the outer temperature, not the inner temperature. They commented that this could lead the physician to think the cast is not as hot inside as it may be.

The researchers conclude that cast thickness should not be overly thick, the dip water should be kept below 24 degrees, and that splints should be fit for the limb and not folded over as this will double the thickness. If fiberglass is to be used, it should not be applied until after the plaster has fully cured. Finally, avoiding use of a pillow is preferable.

Although patients with psychiatric illnesses make up only a subset of orthopedic patients, orthopedic surgeons need to be aware of the issues involved in caring for patients with psychiatric illnesses.

The authors of this study wanted to identify problems associated with orthopedic treatments for patients who are mentally ill. To do this, the researchers studied 40 patients (24 with schizophrenia, 12 with depression and/or anxiety disorder, and 4 with schizoaffective disorder) who were receiving treatment for soft tissue infection or trauma. The group, aged from 15 to 85 years, was split evenly among men and women.

After obtaining histories from the patients and/or their guardians, and a psychiatric assessment at admission, patients who required surgery either signed themselves if they were considered to be competent, or their guardians signed for them. If an emergency arose and the patient was not competent and a guardian was not available, the orthopedic surgeon and the psychiatrist could sign consent if they were in agreement. The majority of the patients (80 percent) were known to have a psychiatric disorder, but only 62.5 percent were under treatment, with the remaining patients with known psychiatric illness not receiving follow-up care. The remaining 20 percent of patients were newly diagnosed.

The patients were watched for any problems that may have been encountered between the patient and the treating doctors. This included patients not appearing for follow-up appointments, non-compliance with treatment, and complications from treatment (including infection, re-fracture or incidents with the cast).

The researchers found that the main problem faced by the subjects was a lack of or poor family support, followed by poor doctor-patient communication, and then the patients’ lack of insight into the problems. After discharge from the hospital for their orthopedic treatment, over half (57.5 percent) did not follow up for further care and 45 percent were not compliant with their treatments.

When the researchers analyzed the patients who defaulted, or did not participate in follow up, they found that 30 percent did not attend the first appointment following discharge, 26 percent did attend the follow-up clinic once. The staff was able to contact 15 patients by phone; 11 of the patients said that transportation difficulties kept them from attending the clinic while the other 4 felt that further visits were not necessary. The staff was not able to contact the remaining 8 patients.

Of the 23 patients who did not appear for follow up, 22 of them were independent. Seventeen patients had a poor family support and of them, 13 did not appear for follow up – accounting for a 76.5 percent rate, compared with those who did have good family support, of whom only 43 percent did not appear for follow up. Again, among the 23 lost to follow up, only 14 patients or 35 percent recovered from their orthopedic problem.

The study authors wrote that the major issues that present when treating patients with psychiatric disorders are those of compliance and defaulting on follow up. They noted that those patients with poorer family support had a higher likelihood of defaulting, and they also found that this group had a higher rate of infection following surgery (almost 59 percent of patients). The authors suggested 7 aspects in which care could be improved for patients with psychiatric patients who need orthopedic treatment:

1 – A better understanding of psychiatric and psychological medicine
2 – Restructuring treatment to minimize patient non-compliance, such as providing easy-to-understand instructions and good patient teaching about patient outcomes if the patient is non-compliant
3 – Encouraging family support
4 – Recruiting community support, such as community or home care nurses
5 – working with psychiatric services
6 – Adapting orthopedic treatment options to fit each case
7 – Working with rehabilitation

In conclusion, the authors say that the orthopedic surgeons must take into account total patient care in order to provide proper care for patients with psychiatric illness who have orthopedic problems.

Osteoporosis, thinning of the bones, occurs in about 25 percent of all American Caucasians. Many more have low bone density and are at risk of developing osteoporosis.

Bones develop through modeling; they adapt according to the amount and type of stress to which they are subjected. This is done with the help of calcium, some hormones such as estrogen and androgens, vitamin D, parathyroid hormone, and growth factors. Bone mineral density peaks in young adulthood and begins to decline. How much and how quickly it declines depends on several factors.

The better the bone mass at the peak, the less dramatic the loss of density. According to the author, men usually lose bone at a rate of 0.3 percent per year and women at 0.5 percent per year. Once a woman reaches menopause, the rate rises to two to three percent per year for six to 10 years. After this, the rate of loss drops again to about 0.5 percent.

The author points out several factors that play an important role in bone density: vitamin D, parathyroid hormone, calcitonin, estrogen, glucocorticoids, and thyroid hormone.

Estrogen plays an important role early in life as well. If a girl misses several periods or has no menstruation at all, she may be losing bone mass every year rather than gaining it. This loss of bone mass cannot be recouped later on.

If a doctor suspects a patient may have osteoporosis, a thorough evaluation is necessary. This begins with a medical history and physical examination, followed by blood tests (to exclude other diseases), and imaging studies to examine the bones and their density. These include x-rays of the spine, a single-beam densitometry of the forearm, computed tomography scanning (CT scan) of the spine, and/or dual energy x-ray absorptiometry (DEXA). If necessary, a bone biopsy may also be needed.

Prevention of osteoporosis starts with lifestyle changes. These include eating a diet rich in calcium. Recommended daily allowances of calcium vary with age: 1000 mg per day for a healthy adult under the age of 65 years, and 1500 mg per day for women who are post-menopausal. Physical activity is important while children are growing for bone building; in adulthood, exercise can help maintain bone density. The author also mentions the use of hip protectors to help prevent hip fractures.

Medications may help reduce the risk of fractures. Supplements of calcium and vitamin D (500 to 1000 mg per day) may slow the rate of bone mass loss in the elderly who do not consume enough dietary calcium. A recent study showed that although vitamin D itself did not provide a reduction in fractures, vitamin D did help reduce risk if combined with calcium. Hormone replacement therapy (HRT) is also used. The author points out that several small studies have confirmed the efficacy of HRT in raising the BMD and reducing the risk of spinal fracture by 50 percent, while another study found a reduction of 37 percent in fractures of the vertebrae. The serious adverse effects of HRT do, however, limit the patients who may benefit.

Selective receptor modulators (SERMs) are medications that act like estrogen, but without some of the effects that estrogen has on other parts of the body. These are promising for osteoporosis management. As well, a drug class called bisphosphonates can reduce the chances of spinal fractures, as can supplementation with calcitonin. Finally, for some patients, injections of parathyroid hormone may help, as may the use of strontium.

The author concludes with the following recommendations for orthopedic surgeons who see patients with osteoporosis:

– counseling for women at risk
– counseling regarding dietary needs for bone strength and to avoid alcohol and tobacco
– recommending weigh-bearing exercises for bone and muscle strength
– BMD testing for women over 65 years
– BMD testing for women who are postmenopausal and who have had a fracture
– begin therapy in women who are considered to be at risk for osteoporosis
– consider osteoporosis treatment for postmenopausal women who have had a spinal or hip fracture

Older adults experience many effects of aging. Some of these include decreased muscle strength, poor balance, and stiff joints. The result is often loss of function, decreased physical activity, and falls. Experts say exercise is the answer, but how much and what kind?

In this study, the effects of five types of exercise were compared in older adults. Each person was assigned to one of these exercise groups: aerobic, resistance, balance, flexibility, or Tai Chi. Exercises were done two to three times each week for 12 weeks.

The results were measured using specific tests of strength, balance, flexibility, and aerobic capacity. These tests were designed to assess functional fitness (FF). FF was defined as the ability to do activities of daily living (ADLs) easily.

Once the data was analyzed, the authors reported the following:

Osteopetrosis is a hardening of the bone that leads to problems with fractures, arthritis, and osteomyelitis (bone infection). In this update and review of osteopetrosis, classification (type), pathology (what went wrong), and signs and symptoms are presented. Treatment is also discussed.

Osteopetrosis is caused by genetic mutations and is an inherited condition. There are three main forms including malignant, intermediate, and benign. Most cases are the benign form.

The pathology behind this bone condition is a problem with the osteoclasts. Osteoclasts are bone cells that remove bone tissue. This process is known as bone resorption.

Bone resorption is part of a normal building up and tearing down of bone cells. But in osteopetrosis, the osteoclasts can’t remodel bone during growth. Instead, the bone stays thick with bone cells in a disorganized pattern. The poor bone quality leads to hard but brittle bones that fracture easily.

Symptoms can be mild to severe depending on the type of osteopetrosis present. The malignant form occurs in the first year of life. Most children with this type do not survive.

The intermediate form occurs later in life. Fractures are the first sign of a problem. Bone growth around cranial nerves can cause neurologic problems. Cranial nerves come directly from the brain instead of the spinal cord. They send and receive motor and sensory messages in the head and neck region. Hearing loss and blindness can develop.
This type of osteopetrosis is less severe than the malignant form.

The most common type (benign) can occur at any age. Frequent fractures that don’t heal well affect 60 per cent of these patients. The fractures lead to bone deformity, which can result in osteoarthritis (OA). Spine problems such as scoliosis (curvature of the spine) and low back pain have also been reported. The remaining 40 per cent of patients with benign osteopetrosis may not have any symptoms.

In this update article, experts in arthritis present the latest findings on fibromyalgia. Epidemiology and pathophysiology are presented.

Epidemiology includes the characteristics of people affected by fibromyalgia. Pathophysiology is the underlying mechanism (what went wrong). Understanding these two features of any condition helps doctors find the right treatment.

Fibromyalgia or fibromyalgia syndrome (FMS) is a collection of symptoms starting with chronic pain and tender points in many areas of the body. Muscle, joint, or bone pain, and fatigue are present along with a wide range of other symptoms. Women are affected most often, but men can have this problem, too.

A problem with regulating pain in the spinal cord and brain is the most likely cause of FMS. Something triggers the nervous system to register pain sooner and more often than necessary.

This pathophysiologic concept is called neural dysregulation. The person with FMS has increased pain sensitivity. This is referred to as central sensitization and is the focus of new drug treatment. The goal of drug therapy is to down-regulate pain signals.

The FDA has approved the first drug (pregabalin) specifically for FMS management. Other drugs such as anti-depressants and analgesics (pain relievers) are still in use. Many doctors prescribe a combination of drugs. The hope is to decrease pain and fatigue while improving sleep.

Research is focused on finding the right drug in the correct dosage for each affected individual. Higher doses seem to work better but can bring on other unpleasant side effects. Drug therapy should always be part of a total management approach.

Education, exercise, behavioral therapy, and family and social support are important. Many patients are also helped by complementary and alternative medicine (CAM). This includes treatment such as hypnosis, acupuncture, massage, and naturopathic medicine.

This is the first of a two-part series to discuss the management of football injuries. Injury to the upper extremity is the topic of this first article. Common injuries to the lower extremity will be covered in the next article.

Football is associated with a high rate of injuries. Up to 80 per cent of the players are hurt, sometimes fatally. Fracture, dislocation, and concussion are the most common injuries.

Trauma can be classified as contact or noncontact. Contact refers to injuries as a result of tackling someone else, being tackled, or blocking. Noncontact injuries occur during running, jumping, cutting, or landing.

Each player is susceptible to specific injuries based on their position. For example, the quarterback wears less protective gear. This allows him greater freedom when throwing the ball. But shoulder injuries are high when they get tackled. Running backs are injured the most often. They frequently have to change speed and direction causing knee injuries.

Wide receivers, defensive backs, and linebackers are each at risk for injuries based on the skills required by their role. The authors of this article discuss each one thoroughly.

The physician’s job managing these injuries on the field is also presented. Emergency care is often needed. Decisions must be made whether the player can return to the field. Blunt-force trauma can cause very serious injuries leading to paralysis or death.

Specific injuries to the head, neck, spine, shoulder/elbow, and wrist/hand are discussed in detail. The incidence of brain injuries is very high among football players. Players must be observed carefully for any signs of internal bleeding, fractured skulls, and signs of serious concussion.

Each team has trainers, therapists, coaches, and other specialists involved with the players. A well-planned coordination of everyone concerned is needed to manage all injuries whether minor or severe. Players must be taught not to hide injuries. Playing when there are potentially serious injuries can have major negative, long-term effects.

When trauma occurs affecting the bones, fractures and bone loss may be an added complication. Surgery is often needed to stabilize the area. Healing may be delayed. Bone grafts can be used to help fill in gaps and speed up the process.

The subject of this article is the new bone substitute material available. There are several different types of chemical compounds on the market. Studies to compare them are very limited. For now, the surgeon is on his or her own to know about each one and to choose the best product for each patient.

Dr. D. J. Hak from the University of Colorado School of Medicine summarizes information about bone graft substitutes. He specifically offers the pros and cons of using five substitute products. These include coralline hydroxyapatite (Pro Osteon), collagen-based matrices (Collagraft or NeuGraft), calcium phosphate cement (Norian SRS, Callos) calcium sulfate (Osteoset), and tricalcium phosphate (IsteoMax, Cerasorb,and many others).

These products vary in strength, composition, and the rate that the bone grows or is absorbed. They come in various forms such as pellets, paste, blocks, or granules. Bone graft substitutes are not used alone. They must be used along with instrumentation. Instrumentation refers to plates, screws, and wires used to hold bone fragments together.

Sometimes bone graft substitutes are used along with bone harvested from the patient. The combined use may be needed when the bone defect is very large. The surgeon may choose the substitute based on whether it works to fill in a structural defect or extends across an open fracture site.

The surgeon must be aware that new bone formation is different from person to person and from bone to bone. This is one of the reasons why research results are so limited right now.

The surgeon must also keep in mind when bone graft substitutes should not be used at all. Patients who have osteomyelitis are not good candidates. Anyone who is sensitive to collagen products can’t receive the collagen-based matrices.

The surgeon has many other factors to consider. For example, problems can occur if the body absorbs the bone substitute too fast or too slow. Infection is always a concern. Sometimes, the tissue just won’t accept the new bone material. The cost must also be considered, especially if the results are poor.

The author reviews the outcomes of studies published so far for each material. He stresses the need for each surgeon to know the products well before using them. Choosing the right patients and using the best material for that situation is very important.

In order for researchers to develop therapies to prevent or treat bone fractures, it’s important for them to understand what makes up a bone and why. In this article, the author discusses the make-up of different types of bones and why they act as they do.

The numerous bones in the human body have different roles. While some are for support, others are for weight-bearing. Yet others, like the bones in our ears, are used to transmit sounds. Each role requires a different type of bone. The bones also have to accommodate certain requirements. They must be strong enough not to break unless under extreme force, yet they must be able to absorb impacts and to resist becoming deformed.

To be strong enough for its role, the bone material stiffness and flexibility is determined by its mineral content. For example, the bones in the ear are much more mineralized than the bones in your hips. Some bones are tubular, while others are flat and formed. According to what researchers know about bones, the larger bones have a lower bone mineral density (BMD) than do the smaller ones, and the longer bones are more resistant to bending because of their composition. These longer bones are, therefore, stiffer than others.

The bone growth in females generally stops earlier than in males, but the bone composition still seems to be the same. However, researchers have found that there is a difference in one of the layers of the bone called the cortex.

As the bones grow, they adapt to their assigned job and their shapes are defined by the loads that they have to bear. For example, the bone shape at the thigh. This area bears a lot of weight and it is involved in intensive bending, so the shape of the bone is oval and the cortex layer is thick inside the bone, rather than outside. As you move down the femur (the thigh bone), the shape and make up of the bone changes to adapt to its role of just weight-bearing. Another example is in the spine. These bones, the vertebrae don’t play the same weight-bearing and bending role as does the femur at the thigh level, but the act more as shock absorbers. The vertebrae of men are generally wider than in women, and in some races than in others. Of course, as much as the bones adapt to their job in the body, genetics also play a role.

Since researchers have a good idea of how the bones are formed and why, the focus now comes on how to keep the bones strong or how to make them stronger as we get older. The author says, “The emergence of bone fragility during aging may be regarded as the net result of accumulating abnormalities caused by disease, hormonal deficiency, and excess exposure to risk factors.” He also says that “bone fragility can be viewed as a disorder of adaptation.”

Researchers have found that the first sign of a change in bone structure is the decrease in the way the bone is reforming and rebuilding itself. This is seen a lot in women who have gone through menopause, but it has also been seen to begin in some form as early as age 19 years. As the bone formation after growth has complete, the need for constant regeneration is not as strong, so it slows down. As bone loss begins, this too is different between men and women. In men, the loss is more in the actual mass and the bones thin out. In women, the loss is in the connectivity of the strands of bone. Many women end up with fractures in their vertebrae, as opposed to men, and this can be due to the vertebrae seem to feel the loss of this connectivity a lot more than the other bones in the body.

Another difference between male and female skeletons is the larger skeleton itself. The larger male skeleton is able to handle a larger load than the smaller female skeleton. As the women age, their bones become more fragile and this can lead to fragility fractures, something not often seen in men.

The authors concludes by pointing out that while bones need to be stiff enough to do their job, they also must be flexible enough to bend a bit and absorb shocks. When there is less mineral content in the bone due to aging or bone loss, these abilities are decreased. There is still much research needed to clearly understand the process and the differences between different races.

There’s a general assumption that a delay in identifying cancer leads to an earlier death. The belief is that the duration of symptoms is longer when the diagnosis is delayed. But studies don’t support this idea. In fact, for some cancers, the opposite is true.

For example, a short duration of symptoms with bladder and lung cancer is linked with decreased patient survival. What about soft tissues and bone sarcomas? Sarcoma refers to any cancer that starts in the connective or supportive tissue. This can include bone, cartilage, fat, muscle, blood vessels, and any other soft tissue.

In this study, researchers try to answer the following question. Does the length of symptoms before diagnosis affect patient survival? Information on over 600 patients with bone or soft tissue sarcoma was fed into a computer and analyzed.

Data included how long symptoms were present before the diagnosis was made. The size of the tumor at the time of diagnosis was also included. The researchers looked at the location of the tumor. The presence of metastases (cancer spread) was noted.

The authors report the following findings:

For many years, doctors have relied upon pain relievers and anti-inflammatory drugs to help manage the painful symptoms of osteoarthritis (OA). But recent studies have shown that the most commonly used drug (nonsteroidal antiinflammatories or NSAIDs) may actually cause even more cartilage loss. Cartilage loss is one of the main reasons OA develops.

More and more studies are showing some nutraceuticals may help. Nutraceuticals are natural plant substances used to promote health and prevent disease. In the case of OA, some of these products may be able to reduce the use of NSAIDs. They have other benefits as well such as delaying the need for surgery.

In this report, Dr. J. J. Clayton reviews and summarizes the most commonly used and studied nutraceuticals for OA. There has been enough positive benefit from some of these products to support larger, more long-term studies.

Currently, glucosamine and chondroitin have received the most attention. But other nutraceuticals used in the management of OA include SAMe, boswellia, collagen hydrolysate, and diacerin. Avocado-soybean, curcum (tumeric), ginger, and evening primrose oil are other nutraceuticals that may have some beneficial effect on OA.

The source and effects of each one of these products is reviewed. Findings from current research are included. So far, clinical trials have been limited but the adverse effects of these nutraceuticals are rare and mild. Dosages recommended are just suggestions at this point until more studies can be done.

Questions still remain about the long-term safety of nutraceuticals. We still don’t know if some people are better candidates for nutraceuticals. Perhaps some joints respond better than others to these products. Or maybe the use of nutraceuticals gives the best results when used at certain stages of OA.

More studies are needed to monitor the use of nutraceuticals. Results of using each type of nutraceutical should be compared with results of patients who take NSAIDs and people who do not take anything. This type of study is called a controlled trial. It’s really the best way to know if there are real benefits from drugs and substances like nutraceuticals.

The author advises patients to do the following. If your doctor recommends any one of these supplements, purchase them carefully. Look for products from reputable sources. Be patient. It may take several months to see any improvement in symptoms. Watch for results from large, random controlled trials (RCTs). This will help guide the selection of product type and dosage.

Many studies have been done to better understand the presence of calcium-containing crystals in the synovial fluid, the fluid that helps lubricate the joint, in people with osteoarthritis. Researchers do know some of the risk factors for osteoarthritis. They include age, obesity, overuse or misuse of the joint, and calcification of the joint. In this study, the authors wanted to review what research had been done and any advances during the past year.

Basic calcium phosphate (BCP) crystals are often present in the joints of people with osteoarthritis. BCPs are found in as many as 70 percent of cases and researchers feel that this is only the documented number. They believe that the actual percentage is even higher, even perhaps up to 100 percent. Another type of calcium crystals, calcium pyrophosphate dihydrate (CPPD), are also present in some joints with osteoarthritis, but only in 25 percent to 55 percent. Interestingly, one study found that joints with calcium deposits, or chondrocalcinosis did not have as high a risk of losing cartilage as knees without the deposits. Other researchers found that the presence of the CPPD crystals did not seem to have an effect on when the pain started (age), ease or difficulty in performing daily tasks, or if patients had to use a walking aid, such as a cane or walker.

Why the CPPD crystals don’t have the same effect as the BCP crystals isn’t quite understood. However, there are phosphate ions in the BCP crystals and pyrophosphate ions in the CPPD. Pyrophosphate ions can, potentially, inhibit or block calcification. This is one possible explanation for the difference. Another is that perhaps, unlike BCP crystals, CPPD crystals are not a good way to determine if there is osteoarthritis present. More research, this time from China, has shown that although Chinese men have a rate of osteoarthritis that is similar to white men in the United States, they had a lower rate of calcium deposits than did the Americans. The researchers suggest that this means the calcium deposits and osteoarthritis are not one and the same.

The question of where the crystals come from is likely found in the cartilage, or soft connective tissue in the joints. The crystals in the cartilage are likely released into the synovial fluid as the cartilage breaks down. Other research shows that the calcium crystals help the joint degenerate.

The authors conclude by repeating that the role of the crystals are still not completely understood. It is possible that some of the crystal formation just happens as a part of life, but they may also form because of life activities, aging, or illness. Researchers will have to continue studying the basis of the crystals and their role in osteoarthritis in order to be able to design a medication or treatment to help prevent or reverse the damage.

Rickets, a disorder resulting from insufficient vitamin D, is making a come back in Western countries. A significant portion of Vitamin D can be had from a most natural source, the sun, but with today’s avoidance of the sun because of skin cancer fears, this option has become less popular. As people cover up from fear or cultural practices, avoid the sun by staying inside, and use sunscreen, the sun’s rays are not able to provide the necessary nutrients.

Pregnant women who don’t get enough vitamin D while carrying the child may have children who develop bone mass problems. As well, as breast feeding rates rise, the breastfed babies should receive vitamin D supplements because vitamin D is not passed through breast milk. Finally, as children get older, they tend not to eat the foods that are highest in vitamin D, such as salmon, broccoli, or parsley. Even vitamin D enriched milk may be pushed aside in favor of soft drinks or soda. This provides a double whammy because not only do these drinks not have vitamin D, they can help prevent the absorption of some nutrients needed for bone building.

Taking all this information into account, researchers reviewed the causes of nutritionally-caused and inherited rickets. When looking at vitamin D absorption from the sun, the researchers noted that a sufficient amount of vitamin D would be absorbed within 30 minutes per week for a baby wearing only a diaper, or 2 hours per week for a fully clothed child who is not wearing a hat. People with darker skin do need a bit more time because of the melanin in the skin.

As children grow, their bones form bone mass. Children with rickets are unable to form that mass and this causes softening of the bones, often seen as the bow-legged image that many people have seen. The start of rickets may be seen by x-ray by how the bones are forming and bending out of shape. It’s most obvious around the wrists, knees, and ankles. Once a child with rickets begins to walk, the problems may become more obvious if they haven’t been picked up. Children can also end up with kyphoscoliosis, or a humped back curve of the spine. This happens because the vertebrae, the bones in the spine, are too soft to support the upright weight of the body. Other problems include craniotabes, or softening of the skull bones, a delay in the closing of the anterior fontanelle, or soft spot on the skull, and increased pressure in the skull.

Other parts of the body can be affected as well. They include the teeth and this particular effects seems most common with rickets from pregnancy vitamin D deficiency. The enamel on the teeth may not be strong, the appearance of teeth can be delayed, and there can be an increase in dental abscesses or infections. Children under 6 months old can develop seizures, changes in heart rhythm, and muscle weakness.

As one might think, the treatment for rickets is by providing the needed vitamin D. However, how the vitamin is given depends on the cause. A medication called ergocalciferol is used to treat an acute deficiency of vitamin D, usually daily for 2 to 4 months. Other medications, such as alphacalcidol or calictrol are used for children who have severe kidney or liver problems. If a child is also lacking in calcium, that can be given as a supplement, by mouth.

If the rickets are hypophosphataemic, meaning the child doesn’t have enough phosphate, also needed for building bone, this can be given by mouth. The child does need to be monitored closely because too much phosphate can cause calcium to be eliminated from the body through the urine.

An important point the authors noted was that if a child with rickets needs surgery to correct a bone problem, the rickets must be dealt with first.

When doctors are dealing with neonatal rickets, those caused by lack of vitamin D during pregnancy, the babies will receive calcium gluconate to prevent seizures. First given by intravenous, it is switched to an oral, by mouth, form as soon as possible as the IV formulation is hard on the vein walls. The treatment can be effective within 72 hours but can also take as long as 10 days.

Premature babies also have a higher chance of developing rickets because of how fast they grow; the minerals in their bodies don’t seem to be able to keep up with the rate of growth. Another issue with rickets is lack of movement. People who don’t move can begin to lose bone mass. Children with rickets can’t afford to lose bone mass while being immobile, so physiotherapy is usually ordered. However, this must be done with care because the fragile state of the bones can result in a fracture, or break, which, of course, leads to more immobility.

The authors conclude by pointing out again the increase in the rate of rickets in Western Europe and the United States. They review the importance of recognizing rickets, particularly the rarer forms, in order to begin treatment as early as possible. The importance of education must be emphasized so that children and parents can make the proper food choices.

The growing incidence of vitamin D deficiency is concerning doctors because of the wide range of disorders that can result. Vitamin D can be absorbed from sunlight where it is converted through the skin or absorbed through eating vitamin D-rich foods, where it is converted through the kidneys.

A review regarding the vitamin deficiency was done in 2004 and, since then, more information had come to light about the lack of vitamin D among North Americans, as well as people in the rest of the world. A recent study in the United States investigated pregnant women’s intake of vitamin D. The researchers found that even among women who did take in the recommended dietary amounts, their blood tests showed a deficiency. This happened in 29 percent of African-American mothers, 5 percent of white mothers, 46 percent of African-American newborns, and 10 percent of white newborns.

What is also interesting is the lack of vitamin D doesn’t appear to only cause immediate problems, but may cause longer-ranging ones. A study from Finland found women who had received vitamin D supplements when they, themselves, were infants, had a 50 percent lower risk of developing preeclampsia during their own pregnancies than did women who did not receive similar supplements.

Vitamin D deficiency in the elderly is also up. This can be due to their inability to absorb all the nutrients from their food, lesser frequency of sun exposure, and other illnesses. One study found that vitamin D deficiency could be a predictor of a senior’s need for nursing home care.

The most commonly known effect of vitamin D deficiency is the effect on the bones and muscles. Children who are chronically deprived of vitamin D will not develop strong bone mass and adults will see their bones get softer and weaken. There can also be muscle pain and weakness.

Another study done in the US among post-menopausal women who had broken a hip this time, found that 50 percent had an extreme vitamin D deficiency. In another similar study, 96 percent didn’t have enough vitamin D. There is, however, some debate as to whether adding vitamin D and calcium supplementation for post-menopausal women would decrease the incidence of fractures.

Vitamin D deficiency also affects other parts of the body, as well. It appears to add to the risk of developing arthritis and there may be a connection between the deficiency and colon cancer, prostate cancer, and breast cancer, as well as type 1 diabetes, multiple sclerosis, heart disease, and high blood pressure.

The authors of this study point out that the contemporary diet in North America does not usually meet the daily requirements for the vitamin, and that recommended supplements are only enough to prevent rickets. They would like to see higher dose recommendations, particularly for those who do not get enough or any sunlight. Currently, the most economical and safe recommendation for vitamin D supplementation is 1000 IU (international units) of vitamin D3 alone, a multivitamin with 400 IU of vitamin D3, or a calcium/vitamin D combination of 600 mg calcium and 200 IU vitamin D.

It is also important not to forget the availability of vitamin D from the sun. There is controversy about the sun’s benefits versus risks, however. A recent report stated that there is no guarantee that the sun provided enough of the vitamin for good health.

The authors conclude that orthopedic surgeons are best suited to help patients learn about the importance of vitamin D and bone health.

Medications can be taken that help bone growth. Osteoporosis is a common condition treated with a class of drugs called bisphosphonates. These meds prevent bone resorption. But sometimes, drugs used to treat other conditions such as arthritis, epilepsy, or mental disorders have a negative effect on bone.

In this article, doctors review the most commonly used drugs and their effects on bone. These include anti-inflammatories, anti-rheumatic drugs, psychotropic drugs, and seizure medication. Vitamin K, cholesterol-lowering statins, and antacids are included. Hormones and cancer treatment are also discussed.

Constant use of many of these drugs can slow or alter bone metabolism. This is a problem if there’s a fracture. Delayed bone growth and fracture nonunion can occur. Nonunion means the break just doesn’t heal like it should. In some cases, the drug can be stopped until the bone heals. But as in the case of seizures or mental illness, the drugs are needed and can’t be discontinued.

There are several groups of medications that help improve bone density. Bisphosphonates already mentioned are drugs used most oten for this purpose. But statins used to lower cholesterol have been shown to increase bone mineral density around the hip. Vitamin K and estrogen hormones also protect the bone and prevent bone loss.

Some cancer patients are especially at increased risk of bone loss. For example, men with prostate cancer and women with breast cancer have increased bone loss. This is due to hormone inhibition used as part of the treatment. These patients are more likely to fracture a bone. And children treated for cancer can have long-term effects on bone growth years later.

The authors advise physicians to be aware of all drug effects on bones. Careful monitoring and management of most patients makes a difference. These drugs can be prescribed in such a way to minimize the bad effects while gaining the benefits. With careful planning and attention, the negative effects can even be prevented for some patients.

Stress fractures occur most often in military recruits and athletes. A stress fracture is an overuse injury from repetitive loading of bone. It is brought on by vigorous weight-bearing activities.

Long-distance running, jogging, and marching are the most common causes of stress fractures. Stress fractures are also known as stress reactions, bone stress injuries, and fatigue fractures.

In this study, the medical records of over 150,000 soldiers from Finland were reviewed. All soldiers had been sent to the military hospital for an MRI because of pain caused by exercise. The most common pain pattern affected the pelvis, hip, thigh, or knee.

The goal of the study was to identify risk factors for stress fractures that could be identified by magnetic resonance imaging (MRI). Stress fractures diagnosed by x-ray were not included.

The results showed that stress fractures are most likely to occur in the first eight weeks of basic military training. This suggests the need to look more closely at the basic training program and possibly make some changes to reduce stress bone injuries.

Women are more likely to have stress fractures, especially sacral fractures. This is because of the wide pelvis and leg alignment in females. For both men and women, older age, poor physical fitness, and low muscle strength were the most common risk factors.

Age and gender can’t be changed. But fitness and weakness can be addressed early on in the training in order to prevent stress fractures. The authors suggest an injury-prevention program at the start of military training for all recruits, but especially for anyone with the risk factors identified.

In this two-part report, the diagnosis of systemic lupus erythematosus (SLE) is presented. SLE is an autoimmune inflammatory condition. Skin and joint changes are the two most common signs of lupus. Lupus-associated skin (cutaneous) disease is the focus of this first part. However, many organs of the body can be affected by SLE.

Many skin changes can occur with lupus. The doctor must be careful not to think every skin change is a sign of this condition. The most common skin lesion linked with lupus is a butterfly rash across the nose and cheeks.

A patchy, red rash across these two part of the face forms the shape of a butterfly. A lupus rash can also affect other parts of the body such as the arms, hands, and fingers.

The rash may be flat but can be raised up, forming scales or blister-like lesions called vesicles. The skin is photo-sensitive meaning it gets worse when the skin is exposed to the sun.

The skin lesions do heal and usually do so without scars. Many patients have a permanent change in skin color with a loss of skin pigmentation. Sometimes there are tiny, but permanent blood vessels or spider veins across the skin.

The authors describe in detail skin changes seen with an acute, subacute, and chronic case of SLE. There is a form of lupus erythematosus (LE) that only affects skin. This type of lupus is called discoid lupus. Discoid lupus refers to the disc-like or coin-shaped lesions on the skin. Various medications can bring on discoid lupus. These drugs are listed for the reader.

Treatment of cutaneous LE is the subject of the second part of this report. The second article will be printed in a later issue of this journal.