Discussion on Double Crush Syndrome

Double Crush Syndrome (DCS) is described as compression of a peripheral nerve at more than one site. Scientists have theorized that compression at one site can be asymptomatic, but cause increase risk of impairment at another anatomic site, thus the double crush of the nerve. When the nerve is disrupted at both sites it can result in a change in nerve function nutrient flow at the axonal level and increase the chance that distal nerve axons also become compressed and often symptomatic.

Since being identified in 1973, there has been a lot of controversy surrounding the pathophysiology of double crush syndrome (DCS). There is no way to confirm objectively that the symptoms attributed to DCS are due to injury at two distinct sites and often the patients diagnosed with DCS have multiple comorbidities, other symptoms, and disability. Often the result of diagnosing an individual with DCS is encouragement to seek out surgical repair that may not be the most effective treatment, particularly when multiple comorbidities and disability coexist. Even with the surrounding controversy, it is important to identify that Double Crush Syndrome is a possibility and that a patient’s symptoms may not be related to only one site of nerve compression, multiple sites or even a systemic neuropathy can also be at play.

Many studies have attempted to identify the physiology, the risk factors and the frequency of DCS in the general population. The results have varied so significantly that it is difficult to define how common it is and which populations may be at greater risk. There is some consensus that there is an increased risk of nerve compression injury after systemic illness, such as diabetes, hereditary neuropathy, uremic neuropathy, hyperthyroidism, vitamin deficiency and chronic alcoholism. Researchers have found for possible mechanisms for DCS, the most common being a disruption in axonal nutrient flow due to the compression injury. Other reasons may be an immune response inflammation of the dorsal root ganglion portion of the nerve, an ion channel regulation issue, or a potential neuroma.

The most common diagnosis of DCS is with patients who are unsatisfied with a Carpal Tunnel release procedure. Researchers identified characteristics that differ between those with DCS compared to Carpal Tunnel Syndrome (CTS) alone and have found that in comparison to patients with only CTS, patients with DCS have greater incidence of radiating pain closer to the neck and shoulder, more parathesias and less numbness, decreased grip strength. Some of the classic tests for CTS, including Phalens and Tinnels, were also less frequently positive in those with DCS. It is important that the testing physician be able to identify these subtle differences that distinguish double crush syndrome from carpal tunnel syndrome, as it will allow for more appropriate treatment referral.

Double crush syndrome can also take place in the lower extremity, however there is less research available investigating the occurrence and risk factors for DCS in the legs. In general, the physiology of DCS can take place in any nerve. Examples of DCS in the lumbar nerve roots and associated peripheral nerve have been describes, as have injuries to the sciatic nerve and peripheral nerves. Trauma seems to be a large risk factor for DCS in the lower extremity, including acetabular Fractures of the Hip, posterior hip-dislocation-precautions/topic/45″ class=”alinks-link” title=”Hip Dislocation”>hip dislocation, and lumbar compression. DCS is also associated with ankle injuries resulting in tarsal tunnel syndrome where the posterior tibial nerve is compressed under the flexor retinaculum.

Treatment for double crust syndrome should be initiated with conservative measures that focus on distinct management of each individual lesion. This may include oral steroids, steroid injections, NSAIDs, relative rest to avoid irritating movements and positions, and physical therapy. It is important for the patient to understand that the treatment will involve both the area of pain and the secondary lesion contributing to symptoms, for example treating both the neck and the arm when dealing with carpal tunnel syndrome. If conservative measures fail, surgical consideration can be taken and may include cervical spine decompression and peripheral nerve decompression. This will include procedures such as cervical discectomy, fusion, total disc replacement, posterior laminoforaminotomy, 1st rib resection, or resection of a muscle. The decision as to where to focus surgical efforts first will depend on severity of symptoms and compression at each site. It is imperative that management, surgical or conservative, should focus first on accurate diagnosis and then treatment of all contributing elements.

Risks and Complications with a Blood Transfusion During Total Hip and Knee Arthroplasty

Transfusions of packed red blood cells are fairly common for patients undergoing surgery, especially for a total hip or total knee replacement, due to blood loss during the procedure. Some studies have shown rates for blood transfusion with a joint replacement to be between eighteen and sixty-eight percent. There has been a push by hospitals and orthopedic surgeons to minimize the use of blood transfusion for reasons of cost, supply concerns, inappropriate use, serious complications, prolonged hospital stay and mortality. Studies that indicate complications and overuse tend to focus on the after effects, but are not accounting for the fact that many patients requiring a blood transfusion after joint surgery are likely to have preoperative risk factors as well. To look further into this effect research needs to better understand the reasons for and the patient status prior to the transfusion in order to better understand the risks afterward. This study has been set up to try to determine, for hip and knee replacement, the preoperative factors associated with needing a blood transfusion and the onset of serious complications in the first thirty days post surgery.

The National Surgical Quality Improvement Program is a nationally validated, outcome based program which collects data about preoperative risk factors, variables during surgery, thirty-day postoperative complications and mortality rates. This database was used to identify patients undergoing elective primary hip and knee replacements in 2011. A total of 9362 hip replacements and 13,622 knee replacements were identified. Demographic characteristics such as age, sex and race were noted as well as pre surgical factors such as body mass index (BMI), diabetes mellitus, smoking, alcohol use, congestive heart failure, hypertension, bleeding disorder, and other chronic conditions. Lab values and surgical variables such as duration of the procedure and American Society of Anesthesiologists (ASA) class were noted. The thirty-day complications of interest included infection, venous thromboembolism and mortality.

For this set of patients the blood transfusion rate for hip replacement was 22.2 percent, and for total knee replacement 18.3 percent. Significant risk factors associated with needing a blood transfusion were similar for both knee and hip replacements and included (in order of importance) increasing age, preoperative hematocrit (red blood cell count), BMI 2. These results were somewhat surprising, for example the authors did not expect lower BMI to be associated with increased transfusion requirement, and they also found that smoking was actually a protective factor against needing a transfusion.

This study did not indicate that having a blood transfusion made the patient any more likely for serious complications including infection, venous thromboembolism or death. Some other studies have shown some increase in such complications with blood transfusion, but the studies mentioned here by Pedersen et al and Browne et al were smaller and limited only to total hip replacements.

In any observational study there cannot be proven causality, but the authors feel that this study has used a high quality database, large sample size and comprehensive analysis of preoperative factors, and can provide useful information. This study has shown that blood transfusion following total joint replacement is fairly common and generally safe.

Does Having a Fear of Movement Change the Benefits of Physical Therapy for Those With Sciatic Back Pain?

Sciatica or a radiating leg pain from low back issues is a common and uncomfortable physical problem. Studies indicate it can happen in up to 34 percent of adults each year. The good news is that it usually improves with time. Unfortunately, sciatic back pain has significant negative medical, financial, social, and work-related impacts. This type of injury tends to take longer to get better and is often more disabling as it hurts to move. Recent reviews of the research state that there is not enough evidence to make a recommendation for or against using Physical Therapy (PT) or a structured exercise program for people with this back and leg pain condition.

This study aimed to investigate whether patients with kinesiophobia (fear of movement) improved any more with PT and general practitioner advice (intervention group) compared to receiving care from their general practitioner (control group) on returning to normal movement and medication alone.

135 patients with acute sciatic qualified for this study and were randomly assigned to either the control or intervention group. These groups were again divided into high or low kinesiophobia groups based on surveys and their exam results. Each group was assessed at three months and one year following their treatments.

The results found that patients with high levels of initial fear of movement due to their radiating leg / sciatic back pain benefited more from PT considering their significantly improved measures of reduced leg pain one year following their treatment. At three months after the start of their pain episode, 68 percent of the patients reported improvements in recovery from their sciatic condition (73 percent of which were in the intervention group and 63 percent were in the control group).

One year after the start of their pain episode, 73 percent of the patients reported significant improvements towards complete recovery (82 percent of which were in the intervention group and 63 percent were in the control group).

Researchers in this study were surprised that patients randomly assigned to the PT intervention group did not show more improvements at the three month follow up, as this is when they were getting their most intensive treatments. This study concluded that in this rather small sample population of persons with sciatica, there is good evidence to support that the higher the level of kinesiophobia and pain initially, the better the chance they will benefit from decreased leg pain intensity after their Physical Therapy and general practitioner intervention at the one year follow up.

Use of Orthosis (brace) or Not for Thoracolumbar Burst Fractures

Treatment for thoracolumbar burst fracture traditionally included surgery, bracing and long term bed rest. In recent years this treatment is changing because of the increased medical risks that go with long term bed rest. There has also been some interest in treating these injuries without surgery as well, again because of risks and increased costs associated with surgery. But, there haven’t been many high quality studies to determine the best course of action. Bailey et al have tried to create a study to provide information for medical professionals to reduce risks, improve outcomes and decrease costs after a thoracolumbar burst fracture.

This study compared ninety six patients who had a thoracolumbar burst fracture without any nerve damage. Forty seven patients were fitted with a thoracolumbosacral brace and forty nine were treated without any brace at all. The people with the brace used it for ten weeks. Both groups were given a lifting restriction of less than five pounds and a bending restriction not past ninety degrees at the waist for eight weeks. After this period they were encouraged to return to normal activities. Both groups were given physiotherapy during and after this first restricted period.

Results were measured after three months with a questionnaire. There was no difference between the two groups after analyzing the results of the questionnaire. This study provides evidence that there is no difference between treatment of a thoracolumbar burst fracture with a brace or without one, and that treatment without a brace is safe and effective.

Do Frozen Shoulder and Rotator Cuff Injuries Go Together?

Shoulder injuries are pretty common, but there is one that is especially frustrating because it seems to come on out of no where, frozen shoulder. Frozen shoulder is known in the medical field as adhesive capsulitis and presents as a loss of range of motion (ROM) with no known cause. This definition is quite broad and many people fall into this category. Many researchers and physicians have recently reported that rotator cuff (RTC) injuries can be quite common with frozen shoulder and some even believe that a RTC injury may be the cause of a frozen shoulder. However, due to the vagueness of the definition many studies about frozen shoulder use very different criteria for the loss of ROM, and this makes these studies hard to compare. This study by Ueda et al hopes to clarify the symptoms of people with frozen shoulder who also have a rotator cuff injury.

This study consisted of 379 shoulders of patients with stiff shoulders with no trauma, diabetes or other abnormalities. Their ROM was measured in standing and lying down and the shoulders were divided into three groups. Group 1 had severe and global loss of motion in all three directions, less than 100 degrees of forward flexion, less than 10 degrees of external rotation and internal rotation reach no higher than the level of the 5th lumbar vertebra. Group 2 had severe limitation in at least one of the three directions, but not in the other two. The 3rd group included all the remaining shoulders with mild to moderate limitation. These shoulders were then imaged with MRI or ultrasound to determine if there was injury to the RTC.

Group 1 had eighty-nine stiff shoulders with mean ROM measurements of forward flexion of 88 degrees, external rotation of 1 degree and internal rotation reach just to the buttock level. The imaging studies showed that ninety-one percent had no injury to the RTC and nine percent had a partial tear. There were no full thickness tears in this group at all.

Group 2 consisted of 111 stiff shoulders with mean ROM measurements of 130 degrees of forward flexion, 31 degrees of external rotation, and internal rotation reach to the 5th lumbar vertebra. The imaging results of this group showed forty-four percent normal RTC, seventeen percent partial-thickness tear and thirty-nine percent had a full thickness tear of the RTC.

Group 3 included 179 stiff shoulders with mean ROM measurements of 154 degrees of forward flexion, 49 degrees of external rotation and internal rotation reach to the 12th thoracic vertebra. The imaging studies showed thirty-five percent normal RTC, sixteen percent partial tear, and fifty percent with a full thickness tear in the RTC.

The results of this study indicate that if there is global and severe loss of motion with a stiff shoulder, then it is not likely that there is a rotator cuff injury. However if there is loss of motion in only direction, but not as severe in the others, or only minimal loss of motion in all directions there can be up to a 50 per cent chance of a full thickness rotator cuff tear. In this case, getting imaging such as an MRI to look at the RTC is appropriate.

In-Home Rehab with Video vs Face-to-Face treatments following Total Knee Replacement

Total knee replacement (TKA) is a surgery which has been increasing in frequency in recent years. In addition, hospital stays have shortened and people are heading home sooner than in the past. This means that the role of rehabilitation has become more important for these folks, and therapists who travel for in home treatments tend to have a lot of these people on their caseload. In home physical therapy can be time consuming and expensive in rural or urban areas and it there is recent interest in seeing if tele rehabilitation (instruction via video link through the internet) is a viable and quality option. This is the first large study to try and determine if tele rehabilitation is equally effective as face-to-face home therapy after a total knee replacement.

This study included two groups, one who had in home physical therapy for the first two months following their TKA, and another who had tele rehabilitation for the first two months following TKA. There were about one hundred people in each group, and each group had approximately sixteen sessions of therapy. Progress was evaluated with two well known questionnaires, range of motion, a six minute walk test and a timed stair test based four months after discharge from the hospital.

The treatments were provided by trained physical therapists and were the same for each group. They included evaluation, supervised exercises, instruction in exercises to complete on days without a session, advice about pain control, use of walking aids and return to activities. The intensity and difficulty was based on each individual patients progress.

The results are very promising for tele rehabilitation. This study found that at the last follow up, four months after discharge from the hospital, the mean differences between the groups was basically zero for all the measures. Tele rehabilitation can improve accessibility to rehabilitation services in remote or rural communities, or even in urban areas where volume can be a challenge for in home therapists. And knowing that the outcomes are similar means that as communication technologies become more available, reliable, and affordable, this is a very good alternative for health professionals and patients trying to maximize results from TKA.

Comparing Cost Effectiveness and Outcomes Between ACDF and CDR

The gold standard of treatment for symptoms including long term neck pain, neurological deficits and radiculopathy stemming from the degenerative changes of the neck is an anterior cervical discectomy and fusion (ACDF). It has a very high clinical success rate but is also associated with some negative long term side-effects including loss of cervical range of motion, increased degenerative changes at segments adjacent to the fusion level and an increased reliance on future need to solid bony fusion. An alternative to ACDF was developed for this reason. A cervical disc replacement (CDR) procedure can result in symptomatic relief while preserving range of motionand decreasing degeneration at adjacent segments.

A recent group of large randomized clinical studies investigated long term outcomes comparing ACDF to CDR. They looked at measures including perceived neck function, general health, neurologic improvement and avoidance of future secondary surgical needs. All reported improvement in all outcomes with both CDR and ACDF, with no significant difference between to two procedures. Since CDR is just as beneficial as ACDF but does not come with secondary side effects such as loss of range of motion and increased risk of future deterioration of adjacent segments, it may be the new ‘gold standard’, however another important variable to consider is cost-effectiveness, both short and long term.

Utilizing a patient population targeting individuals over the age of 40 with acute disc herniation and associated radiculopathy, ACDF and CDR were compared with 6 possible outcomes of each procedure: well after primary surgery, nonoperative complication, well after revision, complication after revision, adjacent segment revision, and death. Transitions between the above listed health states were estimated from current literature which included seven studies and over one-thousand total patients. Estimated costs in dollars for each procedure were generated using 2010 Medicare reimbursements for 2010 and quality-adjusted life years (QALYs), were also estimated .

The study found that CDR generated a five year total cost of $102,274, compared to ACDF total cost of $119,814. Furthermore, CDR resulted in 2.84 QALYs while ACDF generated 2.81 QALYs. The cost-effectiveness ratio using these two measures was $35,976/QALY for cervical disc replacement and $42,618/QALY for anterior cervical discectomy and fusion. CDR is less costly and more effective when compared results in a 5 year follow-up span.

Cost-Effectiveness of Minimal Access Versus Conventional Spine Surgery

Surgical techniques for the cervical and lumbar spine can be separated into two categories based on amount of tissue disruption. Minimal access surgery (MAS) is reported to have better short term perioperative results as it utilizes small incisions and minimal muscle disruption. This technique involves use of a tube or sleeve to complete a muscle dilating or muscle splitting approach. Conventional surgery or open spine surgery involves lifting or stripping the musculature along the spine to gain access to the spine.

Patients undergoing minimal access cervical or lumbar surgery report less blood loss, lower chance of infection shorter hospital stays and less pain medication and often a faster return to activity. Long term outcomes of a minimal access surgery are not significantly different from a conventional approach that may involve less favorable short term benefits. On the surface, with results such as shorter hospital stays and a lower chance of infection, it would seem that minimal access surgery would be more cost effective. However, the instrumentation required for these techniques is often expensive and may outweigh the savings elsewhere.

A review of the current literature did not yield any results that compare the cost-effectiveness of minimal access spine surgery to conventional spine surgery for the cervical spine. There were six pertinent reports that met exclusionary criteria that were found comparing the two techniques for the lumbar spine. Surgical procedures in which the two techniques were compared include discectomy, hemilaminectomy, transforaminal fusion, and posterolateral fusion, all of the lumbar spine.

Results of the literature review using these six economic studies comparing MAS with conventional open spine surgery suggest that there is no economic difference between the two techniques. Complications post-surgery, particularly infection were reduced with MAS, and in at least one study they suggest that the minimal access surgery technique for fusion results in lower cumulative costs. Several other studies also suggested cost-saving with MMAS but were excluded from the review as they did not meet requirements of detailed methodology or long term follow up on clinical outcomes. There is a need for more detailed studies comparing cost-effectiveness of MAS to open conventional spine surgery in order to better understand these surgical approaches.

Common Injures of Tennis Players, Their Causes and Treatments

Tennis is a pretty popular sport played all over the world. Matches can be long and there are high forces being generated over and over in the shoulder and elbow. This can result in injuries from overuse in the shoulder and elbow. There are also a lot of quick movements for stopping, starting, and changing direction and this can cause acute injuries in the lower body. This article discusses many common tennis related injuries, why the occur and some basic treatment guidelines.

Changes in equipment have improved performance allowing a faster racquet head which causes higher ball speeds and more spin, but these changes may also be causing increased injury. Increases in racquet and string stiffness will cause an increase in vibration which is transmitted to the arm, and this can create increased forces for the muscles in the arm. Different grips have also been shown to be associated with increased rate of certain injuries. For those using a western or semi-western grip it is more common to have injuries on the pinky side of the wrist and arm, where as those using the eastern grip are more likely to have injuries on the thumb side of the forearm.

Common shoulder injuries are related to the repetitive overhead movements, including the high forces during serving. These include labral injuries, impingements, and rotator cuff injuries and biceps tendonitis. Diagnosis is usually based on physical examination, but can sometimes MRI is requested. Usually treatment for these injures can be non-surgical, improving shoulder blade and muscle function. However sometimes this doesn’t work and surgery is needed to repair damaged tissues.

The most common elbow injury in recreational tennis players is lateral epicondylitis, or tennis elbow. It is more common in recreational players because they tend not to have the correct wrist angle for their back hand, compared to professionals. Most cases will respond well to rest and physical therapy including stretching and strengthening. Sometimes using a larger grip racquet or a brace can improve time to return to playing. If these treatments are not successful the next step is to try a corticosteriod injection and as a last resort surgery to remove the injured area of the tendon, can be very effective.

Injuries in the trunk include abdominal strains. These are usually related to the forces involved in serving. Treatment of abdominal strains includes rest, sometimes even from such simple activities as walking. Then gradual stretching and strengthening before beginning an aerobic conditioning program. Abdominal injuries can last up to or more than six months depending on the severity of the injury, so patience is often required to allow a slow return to play.

Low back injuries can be from a muscle strain or spasm in lumbar muscles. This usually presents with pain or stiffness just located in the back, usually from overuse. A more serious back injury can be from a disc herniation, which can include back pain, leg pain or both. Both these can be treated with rest, over the counter pain killers, and physical therapy. For herniated discs more awareness of movement in the lumbar spine for daily activities and exercises is important. Generally surgery is not needed for these injuries, but time for return to sport can vary a lot. Surgery is usually only indicated if there is frank weakness, bladder dysfunction or persistent pain that isn’t responding to conservative management.

In the lower body, hip and ankle injuries are the most common. They usually involve muscle strains in the hip or ligament sprains in the ankle. Both these types of injuries should respond to rest, ice and physical therapy to improve strength and balance. With ankle sprains, the treatment will be based on the grade of injury and may include a short period of immobilization and then the use of tape or bracing to prevent re-injury.

Fortunately there are successful treatments for most tennis injuries and it usually only means a short time away from the sport. There is also some good research being done on prevention programs to help minimize muscle imbalances and improve form to decrease these chronic injuries of tennis players.

Acute Achilles Tendon Rupture: A Review of the Current Best Practice Advice

Your opponent friend Bob jumps up to grab a rebound in the twice-a-week pick-up basketball game, then painfully grabs his right lower calf muscle’s tendon. He hobbles off the court with one sore heel cord. Bob has just joined the growing population of middle-agers with an Achilles tendon strain. The likelihood of Achilles tendon tears has grown in recent decades.   A recent review of the research has found strong support that men, like Bob, around thirty to forty years and women between sixty to eighty are struck with this common injury.

This review article aimed to add strength to the current ‘weak’ body of research on the appropriate management of torn Achilles tendons.  They highlighted the growing research on best management this calf injury both with and without surgery. The authors dug into the studies on this topic and followed groups of injured study subjects to learn more about the effects of complications (for example, repeat ruptures or infections) and/or successes. They also assessed how well they returned to their prior daily activities in the weeks and years following the tendon tear.

When a patient is examined in a medical provider’s office for this injury, there are many assessment options. Expensive MRI’s, ultrasound tests, squeezing the calf and feeling for a gap along the tendon are some of the common injury tests. This review found the calf squeeze test, also known as the Thompson test was the most effective way to diagnose a full Achilles tendon tear.  The provider should be on high alert for this injury when the patient older than fifty-five, or obese, or is injured participating in something nonathletic, or all of the above.

The role of physical therapy and best-practice plans to improve the patient’s function were reviewed as well.  These well-researched action plans that do not involve a surgical repair were found to effectively reduce the tendon injury from happening again. Patients that opted to undergo surgical treatments had some earlier improvements in tasks like walking and getting back to work, but more recent studies suggested that the improvements were short-lived or minor.

One common problem associated with this tendon injury is a higher risk of a blood clot in the veins of the lower leg.  This study found no support that a tear in your Achilles tendon made you more at risk than any other injury to your foot or ankle. The most common risk factors for a dangerous clot problem were in patients that did not get up and move after their injury and/or those older than forty.

Back Pain in Children: What to Do About It and How to Prevent It

Parents and health care providers that treat children will often hear complaints of their aches and pains. Studies have found that low back pain (LBP) in kids is quite common in kids past the age of eight (varied reports range from six to 33 per cent) and climb as high as 39-71 per cent by the time the child reaches 15 years. Researchers in the Physiotherapy Department at Monash University in Australia decided to comb the research for preventing repeat difficulties of LBP in children. Unfortunately, the existing studies are limited in what health care providers can do to delay or decrease this problematic condition in children.
Hill and Keating a PT/PhD team set about to improve our understanding of the research on specific or modifiable risk factors that increase back pain in children. They found nine predictors of future bouts of LBP in the prior literature, but none of them were supported by follow up independent research reports. Exercise, posture, education, and decreasing causes back pain were studied; however the reviews on what to do about it concluded that more research was needed.

This study looked at 708 participants between the ages of eight and 11, which is the age bracket with the most rapidly increasing prevalence in LBP. They were motivated to focus on an intervention in the study group that encouraged kids to pay attention to their spine posture throughout the day, incorporate a basic back movement program into their daily routine (much like the three-times-per-day teeth brushing model), and educate them on behaviors associated with a healthy back.  The control group was only provided with a basic spine education program.

The results of this study found no relations on the percentage of children reporting LBP throughout the study period following participation in the simple spine exercises, posture and education group. The children in the experimental exercise plus education group did however report less problems with LBP and less first episodes of LBP than their classmates in the education only control group. This study also found support in treating children that are prone to have another bout of LBP if they have had a prior history of LBP.  Five per cent of the subjects with LBP missed school due to their pain, nine per cent missed out on sport participation, and another nine per cent had LBP that was bad enough to visit a health care provider. Thus, any benefit the experimental group may have gained by doing the more active spine program cannot be connected to doing the exercises.  The bottom line found that regular exercise and education appear to decrease low back pain in children between eight and 11 more than education alone.

Information on ACL surgery and rehabilitation based on the Multicenter Orthopaedic Outcomes Network (MOON)

The Multicenter Orthopaedic Outcomes Network (MOON) was created in 2002 to begin collecting information on a large group of anterior cruciate ligament (ACL) reconstructions in order to improve research and treatment. Since then this group has included over 4,400 participants from many surgical centers, and more than 40 publications have used this data. A lot of good information has come from this group which has helped guide surgeons and patients in decisions about their surgery. This article went into detail about many of the findings, but here are a few of the more interesting.

ACL injuries are a common injury to the knee which often occurs in young active individuals and limits their ability to continue to participate in high-level competitive sports. Most people with this injury have a reconstruction of the ACL with surgery. The repair is to done to restore ability for high level sports and to decrease the risk of further wear and tear in the knee. It is estimated that between 175,000 and 200,000 ACL reconstructions are performed every year in the United States and with such a high number of injuries it is important to have high-quality research guiding the treatment decisions.

Of particular interest to this young athletic group is how will they get back to their previous level of sport. The break down for individual sports is as follows: For high school and college football the rate of return to play was in the mid to high sixties, forty-three per cent reported that they returned to the same level of play, the rest either at a lower level or did not return at all. For soccer players, the return to play was seventy two per cent, and of this more than three quarters returned to the same or higher level of play. It appears that a major factor in not returning to play is fear of re-injury.

One of the most important things to consider when having an ACL reconstruction is what to use as the graft. The choice of graft and the patients age were the most predictive variables to success. Use of an allograft (donor, someone else’s, tissue) had a four times greater risk of re-rupture than when an autograft (patients own tissue) was used. Tearing the recently repaired ACL is most likely in the age group 10 to nineteen year olds and then every 10 years the risk decreased slightly. The take home message is that for younger patents the best choice is autograft, with the least chance for re-tear.

For rehabilitation the take home information is that you don’t need a continuous passive motion machine following surgery, but that early knee range of motion was important to prevent stiffness in the knee. Immediate weight bearing is also helpful to decrease pain. Bracing right after the surgery did not offer any benefit. It works fine to rehab at home. Closed chain exercises, like squats, were found to be good in the first six weeks. High-intensity neuromuscular electrical stimulation is safe and believed to improve quadriceps strength, but is not necessary for a successful rehabilitation.

The biggest complication to ACL reconstruction is the risk of re-injury, both of the same operated knee and the other “good” knee. Wright et al, in a study of 460 patients who had to have a revision surgery, found that the most common reason for re-tear was traumatic injury (thirty-two per cent) and then technical error from the initial surgery (twenty-four per cent). This same author discovered that in the first two years after the initial ACL surgery there is a 5.8 per cent chance of tearing the other ACL and an 11.8 per cent chance of re-tearing the repaired ACL.

Another interesting finding made by Mather et al through the MOON group is that in the long term, there is a lifetime cost to society based on whether a person chooses surgery or just rehabilitation following an ACL injury. Looking at the MOON participants and comparing the costs associated with reconstruction, including the medical costs and other things such as lost wages from time off work, and even disability payments, it was shown that the cost to society for an ACL reconstruction was $38,121 compared with $88,538 for rehabilitation only and no surgery. So, it appears that it may be better to have surgery both in terms of knee health, overall cost and quality of life.

The MOON has provided a lot of data for researchers looking into important factors of ACL surgery, and is already helping to guide decisions. There are many more future plans to continue using this as well as other similar large subsets of data to continually improve outcomes from ACL surgery.

Long Term Benefits of Steroid Injection for Trigger Finger

Trigger finger is a common disorder of the hand, effecting the general public and especially those with diabetes. Treatment can include changing activities, using a splint, physical therapy or pain relieving drugs, but the most common treatment is a corticosteroid injection.

Steroid injections have been shown to consistently provide short term relief in many studies up to three years, however there is little proof of long term success from these injections. The reason for this study is to provide information about the long term success rate of a first-time steroid injection for trigger finger.

This is a study of 366 patients who had first-time corticosteroid shot for trigger finger. Sixty six percent were female, forty four percent had multiple trigger fingers, and twenty four percent had diabetes. The researchers looked at medical records for the seven years following injection and if there was no evidence of recurrent or persistent symptoms or need for any further treatment for trigger finger they were then called for an interview. This interview included questioning about recurrence of their symptoms in order to prevent any bias toward patients who did not have follow up with the physician in the form of an appointment.

The results show that for forty five percent of patients there was long term success of the single injection. For female patients the success rate was nearly fifty percent and for males it was thirty eight percent. If there was going to be treatment failure (defined as the need for further injections, surgery or lack of relief) this usually occurred, at eighty two percent, within the first two years. Also having more than one finger with symptoms decreased the chance of success.

Thus females with only one trigger finger are most likely to have success with a single steroid injection, and if there is symptom relief past two years they are likely to continue to experience long term relief.

Prospective Study and follow-up Comparing Operative with Nonoperative Treatment of a Patient with Neurologically Intact Thoracolumbar Burst Fracture

Contrasting opinions exist in terms of preferred or ideal management of burst fractures located at the thoracolumbar region without neurological deficit. In 2003, a prospective study was conducted comparing surgical and non-surgical outcomes for patients suffering from thoracolumbar burst fractures without neurologic deficit. Results demonstrated that there was no significant differences between the two groups with respect to pain, return to work, pain and functional disability. Conflicting positions have been found in other studies. With review of these varying positions it is thought principal differences among the reports may be attributed, in part, to variances in follow-up duration among the studies. The authors of the 2003 study wished to conduct a fifteen-twenty year follow-up of their original patients to find out how their results would pan out over a longer term follow-up. They hypothesized that the original findings would be upheld. Nineteen of the original twenty-four patients treated operatively and eighteen of the original twenty-three patients treated non-operatively were contacted and follow-up data was obtained. The average duration of long-term follow-up was 18.6 years.

Radiologic findings demonstrated that average kyphosis remained thirteen degrees at long-term follow-up in the operative group. No correlation was found between the final rate of kyphosis and degree of pain reported or disability. In the non-operative treatment group the average kyphosis was fourteen degrees at four-year follow-up and at longer term follow-up the average kyphosis was nineteen degrees. Similar to the surgically treated group, no correlation was found between final kyphosis reported and pain reported or disability.

Median pain scores for long-term follow-up demonstrated an average of four cm on the ten cm visual analog scale for those treated surgically and 1.5 cm for those treated non-operatively with a cast or brace. At long-term follow-up there was clinical significance between difference of pain scores between those treated non-operatively and those treated operatively. The functional disability outcome for patients treated operatively measured using the Roland and Morris functional disability score was seven on a scale of twenty five (with zero measuring no disability while twenty-five indicates complete disability). In the patient group treated non-operatively the median score was one. This difference demonstrated clinical significance. There was very little change in the median score over the years in the group treated operatively, however, there was clinically significant improvement in this score within the group treated non-operatively. Median scores on the Oswestry questionnaire at long-term follow-up was twenty for the operative group and two for nonsurgical treatment group. The difference between groups was significant but within each treatment group there was very little change overall throughout the years. Long-term follow-up scores from the short-form-36 showed that nonoperative management was favored to a significant degree.

With regards to return to work status, 58 per cent of patients treated surgically had returned at the four-year point, while long-term follow-up demonstrated that 47 per cent remained employed. Six patients in this group had voluntarily retired and four had lost employment. Of the patients treated non-operatively, 83 per cent were able to return to work at intermediate follow-up. At long-term follow-up 72 per cent were still working while three retired and two lost employment.

The authors of this study conclude that non-operative treatment was the optimal management option for patients with a thoracolumbar burst fracture without neurologic deficit.

Gait Improvements Following Combined Ankle and Subtalar Joint Fusion

In cases of severe bone loss, severe deformity and advanced arthritis affecting both the ankle and subtalar joints, combined arthrodesis (joint fusion) is still indicated. While there is extensive literature regarding the effect on gait with ankle arthrodesis and ankle arthroplasty (joint replacement) there is very little information regarding the objective functional outcomes measured through gait analysis for patients treated with fusion of both the ankle and subtalar joints otherwise known as tibiotalocalcaneal arthrodesis.

A recent study looked to prospectively analyze twenty-one patients who had underwent a tibiotalocalcaneal fusion utilizing a retrograde, intramedullary nail. All patients were able to walk barefoot without use of assistive device and adhered to a gait analysis protocol. The temporospatial measurements included; cadence, step length, walking velocity and total support time. While the kinematic parameters measured sagittal plane motion and total knee and hip motion and the kinetic parameters were ankle power in the sagittal plane and ankle moment as well as hip power. Symmetry of gait pattern was studied by comparing affected and unaffected limbs. This analysis was completed once prior to surgery, while postoperative analysis was performed at a mean follow time of seventeen +/- six months.

This study demonstrated significant improvement postoperatively in cadence, walking speed, step length (of unaffected limb) and total support time. The authors note that the changes in the affected limb may have been attributed to the decrease in pain which would allow for further use of motion of the joints on the unaffected limb or it may be partially attributed to the mechanical stability provided by the arthrodesis. There was significant increase in hip motion postoperatively, which the authors think may represent compensations for loss through sagittal plane motion in the ankle joint. Ankle moment but not ankle power increased postoperatively in the affected limb. Although definitive conclusions could not be drawn from this data, increased hip power may be related to compensatory mechanism due to stiffness in the ankle restricting the ability to “push off” thus the individual would need to pull the extremity forward to advance the limb. Finally, gait symmetry improved significantly following tibiocalcaneal arthrodesis. This symmetry can be clinically useful in correlation with patient perception of their limping affecting both their self-image and overall postsurgical satisfaction.

Bites to the Hand

Animal bites are a fairly common and expensive injury in the United States, affecting about 1.5 per cent of the population and costing over $850 million annually to treat. Dog bites are most common, followed by cats, and humans. Because of the complexity of anatomical structures in our hands and because of the high risk of infection associated with bites, a seemingly small bite can quickly become a big deal.

Bite wounds are very prone to infection due to the high amount of bacteria present in mouths.  Each mammal presents a different prevalent strain of bacteria, each which can cause different problems. The type of wound caused by a bite also comes in to play.  For instance, a bite from a German Shepard may cause more trauma, but a cat bite can easily puncture to the bone, which could lead to easier spread of infection. Human bites are notorious for having a high rate of infection from all of the bacteria present in the human mouth.

Signs of infection can present up to 12 hours after a bite and include a reddening and warming of the skin, swelling, increasing pain and fever.  Evaluation should include personal history, lab tests for infection, x-rays, and a thorough assessment of the wound.  Treatment involves immediate antibiotics and a thorough wound cleansing to prevent further damage by infection. The amount of time between the bite and seeking treatment matters especially with hand injuries and the presence of infection.

New Guidelines for Treatment and Management of Developmental Dysplasia of the Hip in Pediatrics

The American Academy of Orthopaedic Surgeons (AAOS) recently published its clinical practice guideline for detection and nonoperative treatment of developmental dysplasia of the hip (DDH) in pediatric patients. It has been officially endorsed by the American Academy of Pediatrics (AAP), Pediatric Orthopaedic Society of North America, Society of Diagnostic Medical Sonography and the Society for Pediatric Radiology. The intent of the guidelines was to improve treatment and management based on current evidence. The current guidelines used an intense standardized methodology that led to nine recommendations. These recommendations were based on the quality of the evidence. This guideline as well as the AAP Technical Report guideline developed in 2000 continue to support clinical screening of children for DDH. There are some differences between guidelines, though, specifically the age shift in targeted population in the new guideline to include infants only up until six months versus walking age. The nine recommendations include: Universal ultrasound screening, evaluations of infants with risk factors for DDH, imaging of the unstable hip, imaging of the infant hip, surveillance after normal infant hip exam, stable hip with ultrasound imaging abnormalities, treatment of clinical instability, type of brace for the unstable hip, and monitoring of patients during brace treatment. The first two recommendations are the most significant as they are of moderate strength meaning that the benefits exceed the potential harm. Universal ultrasonography screening of newborn infants is not recommended but performing imaging studies before six months of age in infants with significant risk factors is recommended. Risk factors that were determined significant include; breech presentation, family history, and a history of clinical instability. The remaining seven recommendations are of limited strength. These focus on early intervention and management. Only forty-two articles of the 3,990 citations found in peer-reviewed literature fit the rigorous inclusion criteria. It is the authors recommendations that a “concerted and collaborative research effort” is required from the orthopaedic surgeon community to improve the evidence and strengthen the recommendations for future updates of the new guidelines. Readers are encouraged to consult the full guidelines at www.aaos.org/guidelines as discussion of how each recommendation was made as well as the complete evidence report.

Treatment Outcomes in Osteoporotic Compression Fractures: Brace or No-Brace?

Non-operative treatment is usually the first line of treatment for benign compression fractures of osteoporotic vertebrae without neurological injury. These fractures are relatively stable secondary to the nature of the injury occurring from a compressional load versus involving shearing or rotational components. Typically this non-operative treatment has included the use of bracing as well as pain management. In theory braces have been utilized to provide stabilization to the injured site which facilitates alignment, early mobility and protecting it from further collapse. Some noted disadvantages of bracing include muscular atrophy from disuse, skin irritation and deconditioning. A recent research article looked to compare improvements in disability and pain in patients with osteoporotic compression fractures who were treated with the use of rigid, soft or no brace.

In total sixty patients were included in the study and underwent randomization and baseline assessment being allocated to the rigid-brace group, soft-brace group or no-brace group. Patients whom were allotted to the rigid-brace group were ordered on strict bed-rest until an appropriate rigid brace could be fit and applied. The soft-braces were ready made and thus could be utilized immediately upon patient enrollment in the study. In the two brace wearing groups patients were instructed to wear the brace at all times except when lying down. They were instructed to wear the braces for eight weeks. Patients in the no-brace group were instructed to walk without any brace as long as they were comfortable. All participants took pain medication as necessary and were educated on restricting spine movement, heavy lifting and carrying without a specific weight limit during the initial eight weeks. After the eight weeks, a two-week weaning period occurred. The primary outcome measure utilized was a baseline adjusted Oswestry Disability Index (ODI) at twelve-week post compression fracture injury. Secondary measures included pain ratings on Visual Analog Scale (VAS), ODI score, progression of the compression ratio over follow-up visits, general health status, and treatment satisfaction. Baseline characteristics were similar among all participant regardless of grouping. Every participant had one vertebral fracture located from T7 to L3 vertebrae.

The baseline adjusted ODI score at twelve weeks in the non-brace wearing group was not inferior in comparison to the soft-brace or rigid brace group. This primary outcome score was 35.95 points in the no-brace group compared to 37.83 and 33.53 points respectively in the soft-brace and rigid-brace groups, demonstrating a predetermined margin of noninferiority (an ODI score of ten points). There was no statistical difference found in any of the secondary outcome categories. The ODI scores and VAS scores for back pain significantly improved with time in all three groups. Additionally the body compression ratios significantly decreased with time in all three groups. Patient satisfaction in treatment as well as general health status did not differ between the three groups. The authors concluded that treatment without a brace for benign osteoporotic compression fractures did not result in inferior outcomes in patient disability as compared to use of rigid or soft-brace treatments.

Long-Term Effects on Adult Foot Function After Tibialis Anterior Tendon Transfer for Relapse of Idiopathic Clubfoot Deformity Treated with the Ponseti Method.

Talipes equinovarus (clubfoot) is an abnormality that is congenital (present at birth) in which the foot is twisted out of shape or positioning. The Ponseti method of treatment includes serial manipulations and application of casts and braces. Relapse of the deformity has been reported in a prevalence of 7-56 per cent. Relapses are often found to be the result of inadequate, short-term use of bracing and nonadherence to bracing recommendations. Further bracing can be utilized, however, proves challenging as the child ages and is less tolerant of bracing. The use of a tibialis anterior tendon transfer to the outside of the foot can be utilized to maintain the improved positioning that was accomplished with repeated casting. A retrospective review of prospectively collected data was performed to evaluate long-term outcomes on foot function in adults who had been treated for relapsed idiopathic clubfoot in childhood. This review collected data on all patients treated for idiopathic clubfoot using the Ponseti method at the University of Iowa from 1950 through 1967. All aspects of treatment were performed by Dr. Ignacio Ponseti. Follow-up data was obtained on thirty-five of the original 126 patients whom medical records were reviewed. Of this thirty-five, forty percent had underwent the tibialis anterior tendon transfer and served as the study group while the remaining sixty percent who did not undergo the tendon transfer served as the reference group. The average duration of the time between tibialis anterior tendon transfer and follow-up was forty-three years.

In follow-up, patient’s completed three outcome questionnaires: the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire, the Laaveg-Ponseti questionnaire, and the Foot Function Index (FFI). They also underwent a thorough physical examination, standing radiographs, a pedobarograhic analysis with pressure sensor as they walked freely across the room and surface electromyographic (SEMG) patterns were obtained from the tibialis anterior, lateral gastrocnemius and peroneus longus muscles. Results demonstrated that no patients in the tendon transfer group had a relapse or had required additional treatments for clubfoot at time of final follow-up. There was no statistically significant difference in the number of casts required in the initial treatment between the transfer and reference group. Questionnaire results showed no significant differences between the tendon transfer group and the reference groups on the AAOS Foot and Ankle Outcome or FFI. The Laaveg-Ponseti functional ratings were similar in both groups. Physical findings demonstrated that there was no significant difference in passive ankle plantar flexion-dorsiflexion and forefoot inversion. Nor was there significant difference in passive ankle dorsiflexion at any level of applied torque. Motor strength of the tibialis anterior and peroneal muscles was comparable between the tendon transfer and reference groups. Radiologic findings demonstrated that those whom underwent tendon transfer did have significantly smaller anteroposterior talocalcaneal angle than the reference group. They also demonstrated more talar flattening than the reference group of statistical significance. With the exception of more moderate to severe osteophyte (bone spur) formation in the navicular-cuneiform joint in the tendon transfer group overall degenerative changes and bone spur formation were similar between groups. Pedobaraographic analysis did not show any difference of significance between groups. Additionally there was no difference between the two groups in regards to SEMG data for firing times, nor when the tendon transfer group was compared to healthy college age students.

The authors of this study conclude that the results establish the effectiveness for the tibialis anterior tendon transfer in that there was no subsequent relapse of requirement of additional casting or surgical intervention for clubfoot. They noted that while there was greater bone spur formation at the navicular-cuneiform joint and talar flattening was more present upon radiographic evaluation in the tendon transfer group this did not have association with increased pain, greater medication use or difficulty walking. Several limitations were present in this study particularly the low patient follow-up rate of 28 per cent.

Clinical Outcomes for Patients with Rheumatoid Arthritis After Undergoing Total Ankle Replacement as Compared to Those with Noninflammatory Arthritis

Rheumatoid arthritis (RA) is an inflammatory condition in which the body’s immune system attacks it’s own tissues, in this case the small joints in your body. The ankle joint is commonly affected and can lead to great disability in RA patients. In the past, patients with RA who suffered from disabling ankle arthritis often underwent ankle fusion. This has led to complications including wound healing difficulties, great stiffness as there is often involvement of other small joint in the same foot and even tibial stress fracture from limited forward translation of the affected limb. Total ankle arthroplasty (replacement) has been pursued as a way to preserve hindfoot motion. A recent study aimed to investigate the intermediate-term clinical outcomes and safety of total ankle replacement in patients with RA and matched a cohort of patients with noninflammatory arthritis who underwent the same procedure.

A cohort of fifty patients with RA who underwent a total ankle replacement was identified through the Canadian Orthopaedic Foot and Ankle Society. The database was drawn from four centers across Canada. The control group consisted of fifty age-matched patients with noninflammatory arthritis who underwent the same procedure and were obtained from the same database. Besides age, these groups were matched for follow-up time and type of prosthesis. Clinical outcomes were assessed utilizing the Ankle Osteoarthritis Scale (AOS) and the quality-of-life Short Form-36 (SF-36) Health Survey Standard Version 2.0. Twelve patients with RA and one patient with noninflammatory arthritis had undergone hindfoot joint fusion prior to their replacement. Clinical outcome score analysis of the AOS pain scores demonstrated that the RA group had a higher level of pain preoperatively but improved to a pain level that was equivalent to that of the noninflammatory arthritis group after total ankle replacement. There was no significant interaction effect between treatment and rheumatoid or noninflammatory groups in regards to the AOS disability score. The physical component scores for the SF-36 demonstrated that while the health of both groups improved after total ankle replacement, the noninflammatory arthritis group demonstrated a greater mean change and significantly better physical health at final follow up. The mental component scores of the SF-36 demonstrated modest, but significant, improvements in both RA and noninflammatory arthritis groups. Revision rates were found to be 12 per cent in the RA group and 10 per cent in the noninflammatory arthritis group with a mean time to revision of four years and six and a half years respectively. In this study, one RA patient required removal of the implant secondary to deep infection while another patient suffered a superficial wound complication which required a skin graft. The RA group underwent a greater number of additional procedures to manage associated arthritis throughout the foot at the time of the replacement. While the noninflammatory arthritis group underwent a greater number of additional hindfoot procedures after total ankle arthroplasty to help protect the replacement through correcting hindfoot alignment.

Overall the authors of this study feel that total ankle replacement provides good outcomes for patient with RA in the intermediate term. While the overall pain and disability for these patients was worse preoperatively than the noninflammatory arthritis group, this did not negatively impact the outcomes after total ankle replacement.