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Body Mass Index does not appear to have a relationship to pain or disability after rehabilitation for people with mild to moderate low back pain.

Chronic lower back pain ( lower back pain lasting for more than 12 weeks) is a serious health concern that affects 70 per cent to 85 per cent of people at some point of their life. In Australia where this study was done chronic low back pain cost $9.17 billion (yes, billion) dollars annually. The cost accounts for treatment related expenses and missed work. Obesity is also a serious health concern and it is common among people who experience low back pain. This study wanted to examine if there was a link between changes in body mass index (BMI) which is weight divided by height squared (kg/m2) {m is squared}. BMI is classified as follows: 18.5 kg/m2= underweight; 18.5 to 24.9 kg/m2= normal weight; 25 to 29.9kg/m2= overweight; 30 kg/m2 or more obese. BMI has been critizied because of its inability to discern between muscle mass and fat differences in the body.

Research on the relationship between BMI and chronic low back pain has not yielded consistent results. Studies have had inconsistent findings but these two issues present commonly enough that there relationship should be explored. Exercise is a common intervention for both health conditions and known to be helpful in controlling low back pain. Recent findings suggest that exercise may moderate the relationship between obesity and chronic low back pain. This study investivgated the relationship between BMI and exercise-related changes in pain and disability in patients with chronic lower back pain.

The study used 128 people from 18 to 55 years old that had low back pain for 12 weeks minimum. BMI was calculated for each person, a pain scale was used where particpants put a line an 100mm bar; from “no pain” to “worst pain imaginable” and a self-reported disability questionarie. In the study there were no correlations seen between initial BMI and initial pain reports or initial disability questionarie. In the group 77 per cent of the patients were classified as overweight or obese, yet there was no baseline relationship between BMI and pain or disability.

The study lasted eight weeks and each patient went through exercises after there baseline assessment. However, the type of exercises differed among patients, meaning that some used an indoor cycle, some did core stability exercises. Exercise sessions were three to five, one hour sessions with at least one being supervised.

In conclusion, the study considers that the criticism of BMI might be valid. Other measures might be more beneficial is studying the link between obesity and chronic low back pain. An example would to be measure the amount of fat tissue, as that has been linked to chronic low back pain. The study did not report on changes the exercise impact on individual markers of pain or disability. BMI changes are not related to pain or disability changes after exercise in this study.

Studying the long-term outcomes in developmental infant hip dislocation.

Currently the aims for treatment for late-detected developmental hip dislocation are to obtain proper alignment with good femoral head coverage and to avoid complications. In the past, closed reduction with or without traction was common however more open reductions are being performed today. Both closed and open reductions are often followed up by femoral and pelvic osteotomies. This recent study by Terjesen et al aimed to provide more information about the fifty-year outcome of adults who were treated as children for late-detected developmental dislocation of the hip. There have been no studies with this duration of follow-up and it may provide further ideas about what factors at diagnosis might help predict the long-term outcome.

This study looked at seventy-one patients (ninety hips) that were treated between 1958 and 1962 by one group of orthopedists. The patient ages ranged from two months up to five years old at the time of diagnosis. Every patient was treated with open reduction of skin traction at the facility, and the average time in traction was thirty-three days. Following traction a bilateral hip spica cast was applied which effectively casted the hips, knees and feet in slight flexion and abduction. The patients were in the spica cast for a mean time of nine and a half months. After this, further treatments included open reductions (five hips at a mean age of 25.4 months), derotational femoral osteotomy (fifty-four hips within three years of the initial traction treatment), and further reconstructive surgery after the first three years (thirty hips at a mean age of eleven years old); indicating that it was common for there to be an open reduction performed in addition to the conservative traction and spica cast treatment. Total hip replacement is also common later in life for these patients. At the time of this fifty-year follow-up study twenty-six percent of the hips had been replaced.

Interesting findings from this study include a strong association between the results of x-ray and the patient reported functional outcomes. Residual subluxation is seen in this study as a risk factor for the development of osteoarthritis, and one debatable point is how to treat such hips. It has been shown in other studies that without surgical correction such hips will eventually develop arthritis. And it remains the current policy of this particular group of orthopedists to perform a pelvic osteotomy for patients who are under ten to mitigate this risk as best possible.

Over the years the common treatment for late-detected hip dislocations remains closed reduction with traction. However a shorter time period is used and there is no longer routine femoral derotation. This has changed in the past fifty years due to various reasons, including inconvience for the families and fewer beds in the facility. The consequence of this shorter traction period has been that open reduction surgery has become much more common.

The most useful observation made from this retrospective study is the significant improvement in outcomes, both as observed on x-ray and by patient report, if the diagnosis was made before the age of one and a half years (eighteen months). Of the patients who were younger than eighteen months, only nine percent developed arthritis, whereas if the patients were older, forty nine percent developed arthritis. This is a pretty strong argument that if such diagnosis is made before eighteen months, the more conservative treatment may be quite effective.

Am I Getting Shorter As I Get Older? The Verdict In A 15-Year Follow-up Study on Aging Changes In Lumbar Discs And Vertebrae

It seems to be accepted conventional wisdom that gravity has many harsh effects on the human body as we age. Dr. Videman, MD and PhD out of the University of Alberta and his team of researchers attempt to dispel the myth that spine compression causes the shortening of the human stature. Prior research has long focused on either the flattening disc as a culprit in back pain problems, or the deteriorating vertebral body, but very few studies have examined both structures and their relationship. In other words, is it the shock absorber-like cartilage disc getting squished between our spine’s vertebrae or the crumbling spinal tower theory that can explain why we seem to be shrinking in height after retirement.

Subjects in this study were selected from a 232 Finnish identical twins initially recruited in a Twin Spine Study in the late 50’s. Twin populations are particularly interesting, as they tend to tell us a lot about human similarities and differences in the context of aging and genetics. Apparently, this group of men was also highly representative of the average Finnish population and thus an applicable sample population of the typical European descendant’s spine. These selected gents were at an average age of 63 years (ranging between 50 and 79) at the time of the final follow-up, thus putting them at in their late 40’s/early 50’s on the initial measures. Videman’s team took particular interest in the low back or lumbar spine, focusing in on the MRI’s over the years. They tried to precisely measure the consistent changes in structure and form of the discs and vertebrae during five, 10, and 15-year follow-up studies.

The disc height comparisons concluded that we are indeed getting shorter gradually with a flattening of the disc at five years out by approximately three per cent. The 15-year follow-up found a continued slow compression by 8 per cent in the upper discs to 11 per cent in lower discs of the low back. Measurements of the low back’s bony vertebra at five years out could not find signs of any height changes. However, looking at the 15-year follow-up MRI’s, they found significant vertebra height growth by an average of three per cent in the upper vertebrae levels and by five per cent in the lower back vertebrae after 15 years. Thus, our discs do flatten slowly, but the spinal vertebrae keep pace in remodeling or growing taller (as well as wider) with age. Looking more closely at what exactly happens to the disc and vertebrae at their interface, this article found that the once clearly defined junction appeared to have more or less “melted” into one another. This merging of bone and cartilage results in the appearance of taller spinal vertebra and a narrowed or flattened disc. We are getting shorter, but by only .13 millimeters per year on an annual average after middle age. This not-so-incredibly shrinking average man was in line with the average decrease in our standing height by three millimeters from their baseline measured height to their re-measured height at the 15-year follow-up.

It can be confirmed that we gradually lose somewhere between 9 to 13 per cent of our lumbar disc height in a 15-year period around middle-aged, but why? Videman’s team found a lot of variations within the sample population of researched subjects. Some subjects had no measurable loss of disc height, whereas others had significant disc height flattening, due to degeneration. The exact process of degenerating discs and additional vertebral bone growth is speculated in this paper based on other spine-related research. Two proposed explanations include a cumulative micro-trauma theory at the disc-vertebra interface that creates an inflammation process and merging of the cartilage and bone. The second theory suggests a gradual tensioning of the disc pulling on the vertebra that eventually triggers a process of converting the cartilage to bone. Either way, this was a strong paper with a fairly large population size, precise MRI measurements and a 15 years of follow-up research. There was good evidence in this paper that we are losing disc height and gaining vertebral height at a nearly equal rate. Further research was suggested to explore the exact mechanism causing gain in vertebral height.

Cadaver Cartilage Grafts Prove Promising for Large Cartilage Tears of the Knee

A recent review of the most up-to-date research found that large cartilage tears at the knee joint are best repaired with donations from cadavers. The review found that a technique called Osteochondral Allograft Transplantation,. or OCA, is versatile in terms of what kinds of repairs it can help and has the best long-term effects when compared to alternative surgical options.

Chondral is a fancy word for cartilage. Cartilage is a protective layer of rubbery tissue that covers the ends of bones to prevent rubbing. There are two important layers of cartilage in the knee- one layer of articular cartilage that covers the end of each leg bone and your knee meniscus, which resemble rubbery washers that sit on top of the articular cartilage. Both of these can be damaged from trauma (like a side blow to the knee or excessive twisting forces) or they can degrade over time from normal wear and tear. Sometimes, due to abnormal forces across the knee joint, or excessive use with improper form, these pieces of tissue rub and tear earlier in life. This often happens to athletes who perform the same repetitive movements again and again or in athletes with high impact activities. In addition, if there are any muscle imbalances the knee joint moves at the less than optimal angle speeding up the wear and tear on the cartilage. This breakdown in the cartilage causes swelling at the knee, pain, and interferes with a person’s ability to perform their sport or typical functional tasks of life.

Cartilage does not have a good blood supply which means that it does not heal well. What’s more, it has no nerve endings so you do not really realize there is a problem until damage is done. Chondral degradation is graded on a scale from one to five, with five being the worst. Repair options hinge on the size and location of the tear as well as the goals of the patient.

Smaller lesions (2cm^2 to <10 cm^2) or deep tears. Bigger tears are treated by either OCA or by an autologous chondrocyte implantation (ACI). An ACI procedure involves harvesting the cartilage cells and growing them outside the body and then planting them in the effected area. It is worth noting, however, that an OCA is the only back up procedure for a failed ACI. Authors of this review found that an OCA is less invasive (only one procedure), is more versatile, and has better long-term outcomes than an ACI.

The OCA procedure has become refined with time. The cartilage donation must be collected within 24 hours of the person passing away and is taken from people with healthy knees. The tissue is screened for a host of diseases. This process takes anywhere from 14 to 28 days, during which the cartilage is kept at body temperature, its ideal environment. The cartilage is then selected based on a size and location match, as there is a very minimal risk of tissue rejection since there is little to no immune response in cartilage. If the tear is deep and a bone graft is also required then the risk of rejection is only slightly higher.

An OCA procedure includes several different techniques depending on the type of tear. The most common technique is called a plug, where the chunk of torn cartilage, and perhaps bone, is removed and the new piece of cartilage is fitted perfectly in its place with as tight of a fit as possible. If the fit is not completely snug the surgeon can fasten it in using dissolvable materials or tiny hardware that will not disturb the knee function.

Rehabilitation after the surgery is broken into three phases. The first phase is a period of rest to allow the tissue to heal, with the amount of use of the leg depending on the type of repair. Typically phase one lasts six weeks. Phase two is from week six to twelve and involves return to daily activities, strengthening, and full motion of the knee. Phase three is from three months on and involves full return to sport with the guidance of a physical therapist. From six months up to one year after surgery repetitive high impact activities should be avoided.

Long-term outcomes for OCA procedures are promising with the greatest percentage of success in a younger, active population with traumatic onset of cartilage damage less than one year prior to surgery. That being said, however, the numbers are also promising for the non-traumatic middle-aged population with tears greater than 2cm. Authors suggest that an OCA become the standard practice for larger tears of these populations.

Review Article Sheds Light on Improved Surgical Technique For Hammer Toe

Toes are like teeth, you take them for granted until they hurt and then you realize how much you rely on them and are amazed at how much pain they can cause. Toe instability resulting in a rigid deformity is a common foot problem. A recent review article speaks to new knowledge of toe instability and a surgical technique that should be utilized—specifically, repairing the plantar plate.

In a healthy foot the tiny muscles of the feet and toes along with ligaments on the sides of your toe joints (collateral ligaments) and a thick piece of fibrous tissue on the pad of your feet and toes, called the plantar plate, help to resist the forces your toes undergo during walking and running. The second toe is most vulnerable to hyperextension because there is no muscle responsible for resisting your second toe moving towards your big toe. Authors of this review found that the plantar plate is primarily responsible for the stability at the second toe joint. If this plantar plate is torn, due to abuse or trauma, and not repaired the toe instability becomes worse and typically results in a crossed toe.

Toe deformities go by various names depending on the direction the toe goes, but generally speaking a bent toe is called hammer toe which can turn into a toe stuck under or over the adjacent toe. Any deviation from a straight toe is an indication of joint instability and should be addressed to prevent future pain and walking difficulty.

Hammer toe is caused by outside pressure (like high heels), inflamed joints, and autoimmune diseases. Predisposing factors include genetics, a longer second toe, flat feet, and an already poorly aligned big toe. Curled toes, or hammer toes, most often happen to women older than 50 years old whose feet have been pressed into high heeled shoes with narrow toe boxes. Men and younger people can also develop hammer toe, however it is more rare. Often, these deformities are ignored until they become fixed or the bones have fused into place. Fused toes are problematic because as we push off with our back foot while walking the toes must bend and tolerate 40 per cent of our body weight.

Symptoms of toe instability are pain on the bottom of your toe where it meets your foot, toe swelling and numbness, a feeling of walking on marbles, and a gradual change in the direction of your toe towards encroaching on its neighbor. It may be uncomfortable to walk barefoot or feel better to walk on the outsides of your feet. Imaging, such as x-rays or MRI, can diagnose hammer toe. However two simple tests combined show good diagnosis results: a drawer test to test the mobility of the joint, and trying to pull a piece of paper out from under the toe in standing.

Treatment of hammer toe depends on the extent of the instability of the toe joints. Often, people do not seek treatment until the toe has completely crossed under or over and has become rigid. Conservative treatment is moderately effective for early joint instability and includes shoe modification (lower high heels, wider toe box, more cushion), pads placed in the shoes or rocker bottom shoes to redirect the forces across the foot during walking, or steroid injections at the joint (keeping in mind that any steroid relieves pain but does disturb the already fraying tissues). Keeping your foot, ankle, and calf muscles strong can also help, as well as checking in with a physical therapist to help correct any faulty movement patterns further up the chain.

Surgery is a common option, especially for more advanced stages of hammer toe. Two main approaches are used–one accessing the area from the sole of the foot and the other from the top of the foot. Surgeons trim any unhealthy tissues and suture any obvious tears in the plantar plate and collateral ligaments.

In the past the collateral ligaments have been the primary tissue repaired. However, authors found better outcomes with surgery prioritizing plantar plate repair along with collateral ligament repair. They found that this helped significantly with lasting deformity correction and improvement in pain and a person’s ability to function.

Are you at risk for osteonecrosis or arthritis following a talar neck fracture?

In the past twenty years surgical advances have improved for the treatment of talar neck fractures, however there is still a risk of developing osteonecrosis of the talar body and/or posttraumatic arthritis.

The purpose of this study was to see if there is predictive value in the Hawkins Classifications of talar neck fractures for the long term outcomes in respect to osteonecrosis or arthritis. The researchers were also trying to improve on the classification system to better predict outcomes.

Traditionally the system used to describe talar neck fractures is the Hawkins Classification which is divided into the following categories: type I is a non displaced fracture; type II a displaced subtalar joint; and type III, a dislocated tibiotalar joint. The authors proposed further dividing the type II classification into IIA, subluxated subtalar joint and IIB, dislocated subtalar joint to better describe the amount of trauma and possible injury to the blood supply of the talus.

The study then retrospectively followed eighty patients with eighty-one fractures of the talus between 2001 and 2011. They were equally divided between men and women and the age range was from seventeen to seventy-two. A few patients did not return for their follow ups so the remaining sixty-three patients (sixty-four fractures) were followed for a mean of about one and a half years.

Osteonecrosis of the talar body occurred in twenty-five percent of the subjects and the mean time to appearance in radiographs was just under seven months. Forty-four percent of these cases had complete recovery of the vascular system in the talus without talar dome collapse. Within the classification system no patients with type I or type IIA developed osteonecrosis. Twenty-five percent of patients with type IIB classification developed osteonecrosis and forty-one percent of patients with type III classification developed osteonecrosis. These findings do suggest that a fracture with a subluxation or dislocation will increase the risk of developing osteonecrosis. This fits with their hypothesis that more trauma at the talar dome will have a the potential for increased disruption to the blood supply of the talus and subsequently increase likelihood of ostenecrosis. Interestingly no other factors such as age, medical comorbidites, or tobacco use were found to effect the development of osteonecrosis.

In addition to studying the risk of developing osteonecrosis this study also looked at the occurrence of posttraumatic arthritis. At the time of the most recent follow up, fifty-four percent of the patients had radiographic evidence of arthritis. This outcome was more likely with the type III injury, and in the presence of a talar body fracture eighty-three percent of cases developed arthritis. A fracture of the calcaneus or the tibial plafond also greatly increased the risk of developing arthritis to seventy-five percent.

The results of this study suggest that there is a higher likely hood of developing osteonecrosis if there is a type IIB or type III injury, however almost half of these patients had spontaneous revascularization of the talus (return to normal radiographs). This study also confirms that the most common complication following talar neck fracture is posttraumatic arthritis. The authors also suggest that this is the most common reason for secondary procedures such as removal of hardware, arthroplasty and arthrodesis. There is also the possibility that more of these cases will develop radiographic evidence of arthritis over time.

Younger Age has higher risk of short term Failure after Total Knee Arthroplasty

Total knee arthroplasty or total knee as it is commonly called, is surgery that is being performed more and more frequently, with more and younger people opting for a total knee.

It is estimated that by 2030 people younger than 65 will make up one million of the total knee replacement surgeries performed. It has been established that intermediate and long-term failure rates are higher in younger patients with a total knee, however not much is known about the short-term failure rates. The purpose of this study was to determine if patients younger than 55 years old where at a higher risk of getting an infection at the total knee site or having a mechanical failure of the knee prosthetic (hardware breaking anywhere in the total knee) one year after the surgery. After a total knee failure a revision surgery is performed.

The examiners used report information from California hospitals of patients that had only one total knee surgery from 2005-2009. Patients could be any age and male or female. They found that at one year, 1.36 per cent (5301 patients and 72 revisions) of those younger than 50 had a major knee infection and 3.49 per cent (5301 patients and 185 revisions) had a mechanical failure that needed revision surgery. The revision percentage decreased as age increased and those older than 65 had .73 per cent failure rate (74,570 patients and 545 revisions) due to knee infection and .75 per cent failure rate (74,570 patients and 560 revisions) due to mechanical failure. In all age groups men had slightly higher infection rate compared to women (1.04 per cent vs. .68 per cent), but there was no difference in percentages of mechanical failure. People that had multiple (four or more) health issues such as diabetes, anemia, depression, and peripheral vascular disease had higher chances of revision then those without other health issues.

This study demonstrated younger age (less than 50 years old) is a higher risk age for getting infection around a total knee or having it break due hardware failure with one year. While long-term failure rates due to the total knee breakdown are typically attributed to the younger total knee population being more active than their older counterparts, less is known about short-term breaking of the hardware. The examiners give a possible explanation for the higher percentage of revision with the younger population is that revision may be due to the greater amount of arthritis after a major injury that younger patients have. Whereas older patients do not typically have arthritis from a traumatic event in the knee to be replaced. The study also found that hospitals that performed greater than 200 total knee arthroplasties per year had lower infection rates compared with lower volume hospitals. If you are debating getting a total knee and are under fifty, you should discuss this with your health care provider.

A Review of Management of Chronic Pain

Chronic pain is constant pain that lasts long after the expected time frame of healing. For instance, if you roll your ankle you would expect that ankle to be painful for the length of time that it takes for the ligaments and tendons to heal—say a week or so depending on the extent of the sprain. If there was an underlying chronic, or persistent pain, component then your ankle might still hurt six months after the injury, long after the actual tissue damage has corrected itself.

To understand why the pain that people feel is very real we need to look at how we actually feel pain. For 400 years the medical model for understanding pain was simple: when you step in a flame the sensors in your feet feel the pain and a pain signal is sent via nerves to your brain which shouts Tissue is being damaged! Move your foot! Then in the 1960s this model was proven to be much more complicated. Instead of one continuous pathway (foot to brain), there is a pathway going up with three junctions (at your limb, at your spine, and in your brain) and a pathway going down with the same junctions. Each of these junctions interprets pain and can do so in multiple ways via pain sensors.

At the level of your limbs there are two types of pain sensors, which are then further divided into sub categories. Each of these categories is responsible for a different type of pain detection such as hot or sharp. They also each transmit signals to the spine at varying speeds. This explains why when you accidentally touch something hot you quickly pull back your hand but when your leg falls asleep from sitting you do not notice for a while. To make things more complicated, one category of these pain sensors (known as C fibers) sends signals very slowly with generalized information in regards to pain location and are extra sensitive to inflammatory chemicals that your body creates to help to heal itself. As an example, C fibers are responsible for that achy pain you might have after rolling your ankle; the pain is in your foot and a little up your calf even though the tissue damage might only be at the outside of your ankle. Luckily, C-fibers respond well to NSAIDs like ibuprofen so you take a few of these and the pain signals being sent from your ankle to your brain are quieted as the inflammation decreases.

Pain sensors at the next level, your spine, are more complicated. The sensors here are the go-between from your limbs to your central nervous system (think brain and spinal cord). The caveat is these pain sensors can be ignored by your brain. For instance, if you are in a house fire you grab your baby and run out of the house before you realize that your arm is burned. Your arm is obviously hurt, but you didn’t feel it at the time because of your brain sending a message down to your spine pain receptors saying, Override, there are more important matters at hand!

The highest levels of pain sensors are in your brain in multiple locations. At each of these locations pain is controlled by complex relationships between emotions, brain chemicals, and the nerve matrix itself. Your brain determines what pain you acknowledge and what pain you ignore.

Remember that there are three levels of pain sensors going in both directions? If our brains responded to all of the pain sensors signals at all three levels imagine how much information that would be. A key piece to a healthy pain response is for our brain to recognize which signals are important to acknowledge and which ones we should ignore. Or, which signals are telling us that there is actual tissue damage occurring, and which ones are simply saying, this surface is lukewarm.

In people with persistent or chronic pain, their pain response system at one of those three levels has lost the ability to send accurate signals or ignore signals all together. In other words, the communication lines are crossed and even though there is no tissue damage occurring that person is feeling very real pain. Psychotherapy, relaxation techniques, and rehabilitation (physical therapy or occupational therapy) to down-train the hypersensitivity of the pain sensors are all ways the muddled pain system can be addressed without drugs at the brain level and are often rather effective since the brain is the control center of the pain itself.

Drug management of chronic pain is complicated and controversial. NSAIDs (i.e. ibuprofen), aspirin and acetaminophen (i.e. Tylenol) have mixed effects for treating chronic pain depending on pain location. Long-term use of NSAIDs can cause issues in your stomach and intestines. Opiates and opioids (most commonly morphine) has been the standard drug prescribed. This drug class acts at all three levels of pain sensors. The catch is three fold: you develop a dependency, require higher and higher doses, and suffer side effects as a result. Long-term use studies (>6 months) show that opiates lose their effectiveness over time so it is not recommended to take them long term.

More promising are drugs that address the pain at the control center itself: your brain. These drugs include:
1. Anticonvulsants (i.e. gabapentin and carbamazepine)
2. Antidepressants (which low doses address both depression as well as diminish the pain signals being sent)
3. Tramadol (acts similarly to anticonvulsants and antidepressants but can cause many of the same side effects as opiates).
4. Muscle relaxants (i.e. cyclobenzaprine, tizanidine, both which do not have evidence to support the effectiveness of long term use)
More location specific treatments include creams or patches placed on your skin at the pain location such as lidocaine or NSAID patches.

Moderate evidence exists for non-invasive treatment strategies, which include transcutaneous electrical nerve stimulation (TENS) (this confuses your pain sensors and decreases pain by wearing sticky pads with mild current flowing to your skin), hot or cold packs, and acupuncture. Spinal injections or nerve blocks are yet another way to help to manage pain but have mixed results as well.

However, no matter what drug options are used, it should be noted that the most effective way to treat persistent pain is in utilizing multiple approaches and calling on a team of health care providers to help to restore a person’s overall function.

Common Injuries and Treatment Options for the Adult Shoulder

The shoulder is one of the most mobile joints and most complex joints in the human body. It moves in no less than seven planes if you consider only movement at the glenohumeral joint. If you then take into consideration that the shoulder also involves the acromioclavicular and sternoclavicular joints as well as the scapula, the movement becomes even more complex. It is essential that the shoulder joint be controlled by well balanced muscles that control each of the aforementioned joints and the scapula, particularly in athletes that rely on shoudler strength and mobility for their sport. As the shoulder ages, well balanced movement becomes harder to achieve, presenting a challenge in injury prevention and treatment. The three most common shoulder diagnosis in the aging shoulder are rotator cuff pathology, osteoarthritis, and adhesive capsulitis.

Rotator cuff pathology is probably the best known shoulder joint injury, particularly in athletes involved in throwing sports, swimming or racquet
sports, and can vary from tendinitis to a full thickness tear. Aging is associated with an increase in rotator cuff tears, both partial and full thickness. Smaller tears are often successfully treated with arthroscopic
debridement, but this procedure is not as successful for full thickness tears thus leading to surgical repair of the tear. One study showed rates as high as 98 percent patient satisfaction after rotator cuff repair. The next logical question is what the most effective method of repair may be and as expected it depends on the type of tear and the patient (age, post-operative goals, health status, etc). The options are arthroscopic or open repair, single row or double row. WIth a partial tear the tear can be completed to a full tear then repair or it can be repaired in situ, not completing the tear before repair. The former technique is most common, but in situ repairs are showing a lot of promise with research reports of 94 to 98 per cent patient satisfaction. From a biomechanical perspective, double row repairs are stronger but not necessarily leading to an advantage with clinical outcomes.

Augmentation, another major mechanical emphasis in rotator cuff repair, involves using an extracellular matrix to help stimulate tendon healing. The tissue used for augmentation can be an autograft, allograft, xenograft, or synthetic material. Most recently, human dermal allograft shows the most promise with proven clinical results though new techniques for augmentation are being tested with platelet rich plasma and stem cells. Overall, it is important to differentiate age, desired level of sport, and type of sport before deciding on the treatment for rotator cuff pathology.

Osteoarthritis of the shoulder is not as common as the knee or hip, but it is
not uncommon and can be quite debilitating for older athletes. Treatment options include debridement, capsular release, microfracture, glenoid resurfacing, or total shoulder arthroplasty. Again it is important to
differentiate the athlete and desired goals in order to determine the best
treatment. For the older recreational athlete (65 and older), total shoulder
arthroplasty results in excellent long term survival rates and high level of
return to sport. For younger patients (under 50) almost 50 per cent reported unsatisfactory results in on research study after total shoulder arthroplasty and survival rates were much lower than in their older counterparts. For the younger but still mature athlete, the less invasive treatments are thus more common. Though the research is inconclusive as to which option is best for this population, biological glenoid resurfacing is the most recent promising treatment added to the list of less invasive options. The resurfacing can be achieved with an Achilles tendon allograft, lateral meniscus allograft, or dermal allograft.

Adhesive capsulitis is most commonly known as frozen shoudler and is charaterized by a loss of both active and passive range of motion at the glenohumeral joint. It is classified as primary idiopathic or secondary to
another pathologic process, and can often be associated with diabetes or thyroid disease. Treatment with nonoperative management is highly successful and should be the first option. Conservative treatment may include a steroid injection, physical therapy, or both. Operative treatment is considered with recalcitrant adhesive capsulitis or when conservative treatment fails as can be the case more often with younger patients or those with diabetes.

When considering treatment options for shoulder pathology it is essential to consider the patients demographics, particularly age, and desired level of activity or sport participation. While older athletes may have a more progressive or advanced injury process, often they have lower performance goals.

Surgical Options for ACL Rupture Repair

ACL rupture affects an estimated 35 people per 100,000 and can increase based on gender and activity. Female athletes face a two to eight times increase in risk of ACL rupture compared to their male counterparts. With numbers like this, it is not wonder that the annual estimated health care cost for ACL repair is three billion dollars just in the United States. The most common treatment for ACL rupture is surgical repair, though non surgical rehabilitation is also an option. The decision to repair a ruptured ACL depends on many factors, including age, desired level of activity, episodes of instability and general health.

Before reviewing the surgical options for ACL reconstruction, it is important to understand the basic anatomy of the ACL, or anterior cruciate ligament. It is composed of two functional bundles of ligaments, the anteromedial and posterolateral bundle, which are so named due to their insertion sites on the tibia. Both bundles work together to stabilize the knee into flexion. The anteromedial bundle length remains constant throughout flexion and extension of the knee but is most taut at 45 to 60 degrees flexion. The posterolateral bundle is tight with extension but loosens with flexion in order to allow some rotation to take place at the knee joint.

Once the the decision to have surgery has been made, there are several factors to consider including timing of the surgery, technique used by the surgeon, and the graft site from which to build the new ACL. When making these decisions one must look at preoperative range of motion, swelling and strength as well as individual anatomy, post-operative activities and goals.

Timing of the knee surgery is one of the first factors to consider. There is evidence supporting early surgery, as it may lead to improved functional outcomes and decreased rate of future meniscal damage. However, delayed surgery can allow for potential avoidance of surgery all together if the individual is satisfied with their knee function. Allowing more time before surgery can definitely help an individual improve preoperative strength and range of motion.

Preoperative strength of at least 90 per cent of the quadriceps, is correlated with improved long term functional outcomes. Preoperative swelling and limitations in range of motion are correlated with increased arthrofibrosis after surgery. Thus, a preoperative rehabilitation program focusing on decreased swelling, improved range of motion and quadriceps strength is beneficial.

There are two main surgical techniques utilized in ACL reconstruction, single or double bundle. Though the single bundle technique is far more common, with the double bundle technique being used primarily in Europe and Asia, the rupture pattern of the ACL in that individual and their unique anatomy should be considered by the surgeon when making the ultimate decision on which technique to use. Variations in the tibial notch, arthritic changes, multiligament injuries and bone bruising are all taken into consideration by the surgeon with the aid of a detailed flow chart. Outcomes measures detect no difference in long term functional outcomes between the two techniques, with the exception of fewer reported meniscal injuries with double bundle repair. Regardless, it is important that the surgery match anatomical placement of the ligament in order to help restore optimal biomechanics.

After the technique has been selected, the graft site is the next major decision. Typical graft options include bone-patellar-bone autograft, hamstring tendon autograft, quadriceps tendon autograft, and allograft. If a double bundle repair has been selected the bone-patellar-bone graft cannot be utilized. MRI scans can be helpful in allowing the surgeon to determine which tendon may be most useful based on graft size. The long term goals of the patient are also important in selecting the graft site. For example, an athlete that relies heavily on hamstring strength will not want to use the hamstring autograft. Similarly an individual who has to do a lot of kneeling will not want to choose the bone-patellar-bone autograft.

Once the surgery has been performed, several questions arise, including when one can return to sport, what is the chance of re-injury and/or developing osteoarthritis in the future. Return to sport is dependent on many factors including the healing of the graft, the individuals anatomy and the desired sporting level. For those who do not return to high level of sport, fear of re-injury is a common reason. Graft failure rate is about 11 per cent and does not seem to be dependent of the choice of graft site. Several authors have actually reported a higher rate of ACL injury in the opposite leg compared to a re-injury of the repaired ACL. In general, those who do re-injury a repaired ACL are younger and returning to a higher level of activity. Arthritic changes and the development of osteoarthritis after ACL rupture is more common in those who have sustained some meniscal damage or lose range of motion in the knee joint.

Understanding the Effectiveness of Flexor Tendon Repair Protocols

A recent review of all available research papers concluded that there is really not a straightforward recipe for rehabilitation when it comes to recovery from a flexor tendon repair but that the surgical repair techniques have improved.

Our hands’ intricate system of pulleys and tendons allows us the ability to perform very fine motor tasks such as writing or typing. Your finger flexor tendons control the bending motion that allows us to do these amazingly intricate tasks.

The finger flexor tendons attach onto each individual segment of your finger. Notice how you have three points along your finger that you can bend; your fist knuckle, your finger knuckle and finally the end of your fingertip. Each of these knuckles is controlled by a separate muscle, which turns into a tendon and connects to your finger bone. Should any of these flexor tendons tear it becomes quite difficult, if not impossible, to perform the usual things we require of our hands without a second thought, unless the tendon is reattached to the bone.

As it turns out, however, repair of the tendon is just the first step. The tricky part to total recovery is in the rehabilitation of the finger. Following surgical reattachment of the tendon there are two problems that frequently occur. First, the repair itself can fail and the tendon can tear again. Secondly, while the site of the repair itself needs to rest and rebuild, the remainder of the tendon is stagnant as well. As we all know, if you stay in a static position for a long time you tend to get stiff. The same is true for your tendon and actual adhesions or a binding down of the tendon can occur which causes a decrease in your strength and ability to bend your finger. The ideal rehabilitation recipe, or protocol, would account for both of these issues by allowing your finger to move without risking tearing the tendon again.

Prior to the 1970’s, protocols called for a three-week period of total immobility because it was thought that repairs tended to fail during that time. Then two things changed in the mid 1970’s. First, new evidence claimed that some motion–three to five millimeters (about the width of a thin wedding band), was actually beneficial for recovery because it prevented adhesions or binding down of the tendon. Secondly, another team came up with a simple yet ingenious device that allowed patients to extend their finger themselves (since the extensor tendon on the back of the finger was fine) and a rubber band would pull the finger back to its resting position. This allowed for active motion, or exercise of the healthy tendons on the back of the finger, and relaxation of the repaired tendon on the palm side.

Authors of this systematic review analyzed the results of 34 different research papers to compare protocols for flexor tendon repair rehabilitation. They looked at three trends: the difference in success rates between active motion (the patient moving their own finger) and passive motion (movement with the rubber band-like brace), the rate of tendon re-rupturing, and the overall trends in surgical repair.

The outcome of the repairs were mixed with the overall failure rate (meaning decrease in motion following the protocol or another actual tendon rupture) being slightly better with the active protocols (11 per cent) than the passive protocols (13 per cent). Breaking down these percentages makes it slightly more meaningful– for the active protocols five per cent of the failures were due to rupture and six per cent were due to decrease in motion; the passive protocols had a four per cent rupture rate and nine per cent due to a decrease in motion—but these data left the authors unable to conclude which protocol is actually better.

Reviewing the research available left the authors still wondering what the best balance is between active and passive rehabilitation protocols following flexor tendon repair. Luckily, they were able to conclude that during the past 25 years overall trend in tendon re-rupture rates after surgery is decreasing thanks to material advances and improved suturing techniques. So until the perfect protocol is determined at least we know that the rupture rate is decreasing in part to surgical advancements.

Do Hands-On, Spinal Manipulation Treatments Help Resolve Low Back Pain? A Comparative Look At 36 Years of Research.

There is no arguing that low back pain is an illness that burdens a large percentage of Americans. Sadly, centuries of folk cures and decades of research have fallen short predict reduce the prevalence of low back pain. Modern medicine has dramatically improved the health and livelihood in many arenas, but back pain remains an age-old, expensive, debilitating and frustrating… pain.

The average person with back pain and the American health care reform analyst are equally interested in sorting the worthwhile from the worthless treatments for reducing the duration and frequency of back pain episodes. Comparative effectiveness research hopes to shed light on what services should be recommended and reimbursed by insurance carriers. For example, the Cochrane Collaboration, another meta-analysis think tank, in 2010 looked at fifty studies on chiropractic treatments on low back pain and found muddled results across years of research.

… there is … no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in
… low back pain. … Future research is very likely to change the estimate of (the) effect and our confidence in the results.

Double doctor, J. Michael Menke, a doctor of chiropractic and PhD academic out of the International Medical University in Kuala Lumpur, Malaysia, found very little supportive evidence in his meta-analyses on comparative effectiveness of various manual therapies in his review of the existing literature. A comparative effectiveness meta-analysis” was performed to compare the relative effectiveness of various spinal manipulation treatments (from the ancient bonesetter to the modern back cracker), medical management (READ: drugs, injections, etc), physical therapy, and exercise for acute (less than a month) and chronic (more than three months) nonsurgical management of low back pain.

The good news is most pain originating from the muscles and joint in the human body is self-limiting, meaning slowing down, protecting your injury, and letting the body heal will often suffice. Research supports
the notion that 60 to 70 percent of acute low back pain settles in six weeks without any medical treatment. Chronic low back pain sufferers get better in a year without treatment 40 to 70 per cent of the time.
Pain whether short-term or long-term is indubitably unpleasant, so why suffer any longer than you have to if effective treatment is available.

This study looked at 56 spinal manipulation studies published between 1974 and 2010 and classified them into six different treatment categories. The categories included: 95 spinal manipulation studies, 31 exercise studies, 51 physical therapy/physiotherapy modalities (for example, ultrasound, electrical stimulation, and hot packs) studies, 40 usual medical care studies, and 40 control group studies of subjects that received no treatment.

The results found a 96 per cent relative improvement in the first 6 weeks across acute back pain studies was unrelated to treatment. Thus the “carry on with your life” control group and the various treatment groups were
nearly equal in settling their acute pain. The chronic pain comparison analyses found that 32 per cent of the various treatment studies could claim improved outcomes. The balance of the percentage of claimed improvement in the chronic pain comparison analyses can be attributed to everything else (letting the injury run its course). Looking at the printed boxplots of the six treatment categories effect sizes attributable to the passage of time alone, the three largest effect sizes were in the exercise group, then the spinal manipulation group, then the modality group.

This study also examined which spinal manipulation treatment provider did the best job for improving chronic back pain. It was determined in the comparison that getting your spine manipulated in the first six weeks has little influence on the outcome of shortening the duration of your acute pain. Five types of spinal manipulation providers (osteopaths, physical therapists, chiropractors, allopathic medical physicians, and bonesetters) were compared. Spinal manipulation by a physical therapist was found to be most effective, and most variable, in treating both acute and chronic back pain.

In the 36 years and 8,400 patients subjected to comparative spinal manipulation studies research cost from $32 to $80 million. Menke’s comparative analysis makes the bold assertion that ‘equivocal outcomes are unacceptable for this investment’, and funding more research on the topic should be stopped. It stands to reason, that inadequate analytics and methodology throughout the studies could be part of the problem. The take home message was that all of the compared treatments for acute and chronic low back pain are hard to quantify when looking at their relative effectiveness versus letting the injury run its course.

Rotator Cuff Repair and Immobilization

Shoulder rotator cuff repair aims to suture torn rotator cuff tendons and provide them with the optimal environment to heal and minimize chance of retear. Overall retear rates have decreased over the years, but are still a major concern. Better suture techniques have been thoroughly investigated but there is less attention paid to the rehabilitation protocol. Currently the gold standard for rehabilitation after surgery is to wear an abduction brace and begin physical therapy for passive range of motion within the first few weeks. As surgical techniques have evolved from open surgery to arthroscopic surgery, there are questions as to whether this rehabilitation protocol is ideal. Animal studies have shown that longer periods of immobilization are beneficial to healing after rotator cuff repair.

A recent study published in The Journal of Bone and Joint Surgery investigated the effectiveness of immobilization after surgery in human subjects. The goal was to determine if longer periods of immobilization resulted in any clinical differences in outcomes, including shoulder range of motion, retear rates and clinical outcome scores. One hundred participants who met specific criteria and underwent arthroscopic repair of the rotator cuff were randomly sorted into two groups. One group was immobilized after surgery for four weeks, the other was immobilized for eight weeks. After the allotted time of immobilization each participant underwent rehabilitation with a physical therapist that included passive range of motion then progressed to active range of motion and strengthening.

At follow up conducted at six months and 24 months after surgery, there were no statistical differences between the groups with retear rates, passive range of motion or clinical scores. There were more reports of stiffness by participants who were immobilized for eight weeks compared to those immobilized for 4 weeks. Patients were also less likely to adhere to the immobilization guidelines for a full eight weeks compared to those immobilized for four weeks. With no benefit in healing or diminished retear rate gained by immobilization for eight weeks, it is deemed most beneficial to promote immobilization for four weeks after rotator cuff repair. The retear rate in this study was 10 per cent, compared to previously reported rates of 20 per cent to 40 per cent in studies that involved early passive range of motion before four weeks. Thus a four week immobilization period may give the rotator cuff ample time to heal without increased stiffness and decrease retear rates.

Ankle Syndesmotic Injuries

Ankle syndesmotic injuries are involved in 5-10 per cent of all ankle sprains and 23 per cent of ankle fractures. Despite this prevalence, there is a lot of debate regarding proper diagnosis and treatment of this complex injury.

The complexity of the injury to the syndesmosis lies in the anatomy. The convex distal fibula and concave distal, lateral tibia form a syndesmotic articulation and require specific congruency and mobility to accommodate the underlying talus. The fibula must be able to rotate, translate and migrate to allow for normal ankle movement. The syndesmotic articulation must also be stable, and thus comprises four distinct ligaments. The anterior inferior tibiofobular ligament and the deep posterior inferior tibiofibular ligament contribute the most to ankle stability, combining to provide 68 per cent of the stability to the joint.

Ankle sprains that involve a combination of hyperdorsiflexion and external rotation at the ankle are the most common that result in syndesmotic injury. The injury can involve only damage to the ligaments or combine ligamentous damage with fracture. Isolated syndesmotic injuries are often referred to as high ankle sprains and result in pain and ankle instability. Physical examination can be conducted at three to five days after injury with the patient adhering to rest, ice, compression and elevation (RICE) during this time.

Common evaluation stress tests including the squeeze test, the external rotation stress test or cross leg test are considered positive if pain decreases with compression. Physical examination can be conducted
at three to five days after injury with the patient adhering to rest, ice, compression and elevation (RICE) during this time. Radiographic, CT, and/or MRI can be further used to confirm syndesmotic injury including fracture as deemed necessary. The three common syndesmotic fracture injuries include Weber Type C fracture (pronation-external rotation), Weber Type B (supination- external rotation) and Maisonneuve fracture (involving proximal fibular fracture). A malleolar fracture can also result in syndesmotic injury, but this is much more difficult to diagnose unless done intraoperatively with the hook test or external rotation test under flouroscopy.

Traditionally all syndesmotic fractures are treated operatively with screw fixation being the gold-standard. Syndesmotic reduction becomes an important factor with all fixation procedures as malreduction is common and results in significantly worse functional outcomes. Malreduction typically takes place when the fibula is fixed in the wrong position. Malreduction rates decrease from 50 per cent to 15 per cent with direct visualization of the tibiofibular joint. If direct visualization is not possible with the surgical technique, intraoperative 3D imaging show promise in reducing malreduction rates as well.

A second factor of concern with fixation is the elimination of normal movement between the fibula and tibia that is essential for ankle mobility. Suture button fixation is a new technique that may eliminate the latter concern as it is not a rigid fixation like the screws. A recent systematic review showed that suture button fixation resulted in similar healing time to screw fixation, but the patients reported an earlier return to work and less frequent need for implant removal. Restoring normal biomechanics to the ankle joint whether by use of suture button fixation or removal of screw fixation after healing can lead to improved syndesmotic reduction and improved functional outcomes.

Meniscal Tears

Physicians are changing how they manage meniscal tears, according to a recent study that reviewed treatment methods over a seven year period. Often when new evidence shows a better way to treat a problem it takes years for surgeons to alter their practice methods. This study concluded that surgeons have changed their treatment to reflect the most up to date practice. The authors attribute the change in treatment to new evidence and changes in physician education regarding effective treatment. This is good news for the prevention of knee arthritis.

The meniscus is a c-shaped piece of cartilage that is found on both sides of the knee joint sandwiched between the ends of your bones. It serves as a barrier between the leg bones, helps to redistribute twisting forces and decreases the wear and tear on the underlying cartilage covering the end of the bones.

The meniscus may be torn either by degeneration or by acute trauma. Sometimes from a blow to the knee both the meniscus and the anterior cruciate ligament (ACL) tear. A tear typically causes knee locking and catching, swelling, and pain. In the past, the standard treatment for a torn meniscus was removal, or meniscectomy. However, because recent studies have shown 60 per cent of menisectomies result in osteoarthritis (or the wearing away of the cartilage covering the end of the bones), physician education has changed to emphasize preserving the meniscus. The attempt to preserve the meniscus is called a meniscus repair and involves suturing the structure back together as best possible.

Review of over two billion patient records from 2005-2011 showed an increase of 11.4 per cent in the number of meniscal repairs, with young males and patients under 25 years old having the greatest increase in meniscal repair surgeries. Additionally, there was a 48.3 per cent increase in ACL reconstruction in conjunction with meniscus repairs. This data suggests that physicians are changing their method of treatment of meniscus tears to reflect their training and are repairing meniscus when able instead of simply removing the tissue.

Delayed Treatment of Mallet Finger Injuries

Mallet finger typically occurs with jamming your finger, like hitting a basketball with a straight finger, forcing it to bend when not expected. If the tendon that attaches near the base of your fingernail is unable to withstand this sudden force, it avulses or rips out of the bone creating a droopy fingertip. Unless this tendon is reattached somehow, you will never be able to straighten the tip of your finger again. Typically, this does not interfere with your ability to do things. People seek treatment because they are more concerned about how their finger looks. A small percentage of mallet finger injuries can progress to a swan neck deformity where the tip of your finger is stuck pointing down and the middle knuckle is hyperextended in the opposite direction. This does interfere with finger function and treatment is typically necessary.

Treatment options for mallet finger vary depending on the length of time after injury that the droopy finger shows up (its not always immediate). Treatment is deemed successful if there is little or no extensor tendon lag, meaning you are able to straighten your finger fully.

The most conservative treatment option is long term splinting. This involves wearing a specially made finger brace that holds your finger in a neutral position in hopes that the tendon will reattach via scar tissue. This can be anywhere from six to 14 weeks. Most patients see acceptable success with splinting alone, their finger tip may be not quite straight but less noticeably bent, and do not seek further treatment.

Surgery is the next step if splinting does not work. However, recent review of the literature suggests that despite many different applications of surgical procedures, results are relatively no better than splinting alone.

Diagnosing and Managing Cysts in the Knee

Four distinct types of cysts can form in and around the knee requiring medical evaluation and treatment. In this article, surgeons from the New York University Hospital for Joint Diseases in New York City provide a detailed presentation of each one. Background, clinical presentation, differential diagnosis, evaluation, and management are included for each one.

A cyst is defined as an abnormal closed, bladderlike sac (membrane) containing fluid, semifluid, or semisolid matter. The four most common cysts found associated with the knee are popliteal (Baker) cysts, meniscal cysts, proximal tibiofibular joint cysts, and cruciate ligament ganglion cysts. The fluid usually comes from a channel (pathway or connection) between the synovial fluid inside the joint and the cyst.

Each of these cysts may have a unique cause and formation but the clinical presentation is usually swelling with limited knee motion. Patient history is important. For example, a previous knee injury or known trauma to the knee cartilage (e.g., meniscus) or any of the knee ligaments has been linked with meniscal cysts.

The patient may or may not have knee pain. When pain is present, it is usually confined to the joint line, which aids the examiner in looking for the cause. Sometimes, there is a palpable mass but more often a distinct entity cannot be felt outside of the joint. If the cyst causes meniscal degeneration or erodes the bone, knee instability may be present.

Because knee swelling can be a symptom of bursitis, tumors, blood clots, hematomas, and aneurysms (or other vascular problems), it cannot be assumed that the problem is a cyst. Clinical tests specific for each type of cysts may be performed. But the final diagnosis often requires special tests. Diagnostic tests available to the physician include X-rays, arteriography, ultrasound, CT scans, or MRIs. The pros and cons of each test procedure are reviewed for each type of cyst. Examples of each type of imaging study used to diagnose different types of cysts are presented.

Cysts can be very benign (do not cause serious problems) and self-limiting (go away without treatment). But more often, they cause enough symptoms that treatment is required. Arthroscopic surgery may be needed to remove the cyst, end the connection between the cysts and the joint, and repair damage to the knee. In some cases, invasive surgery can be avoided. The physician can aspirate (use a needle to withdraw the fluid) the cyst.

The prognosis for most knee cysts is good. With aspiration or surgical removal, most cysts do not recur. The key to good recovery is an accurate diagnosis. Management depends on the type of cyst and of course, making sure there isn’t a more serious underlying problem (e.g., tumor). The diagnosis can be very challenging. The detailed information in this article differentiating one cyst from another will aid the physician.

Infection After ACL Tendon Graft: What’s the Risk?

The likelihood of a patient with a hamstring autograft having a deep infection after a hamstring autograft for the reconstruction of an anterior cruciate ligament (ACL) is 8.24 times higher than for someone receiving a bone-patellar tendon-bone (BPTB) autograft.

These are the results of a very large study from well-known and respected institution: Kaiser Permanente in California. Almost 11,000 patients from the Kaiser Permanente ACLR registry were involved in the study. These patients were treated in 41 different medical centers in six different geographical regions.

By reviewing the patient records, they were able to determine how many patients who had any kind of ACL graft surgery developed an infection afterwards.

The three main types of ACL grafts included: 1) hamstring autograft, 2) bone-patellar tendon-bone (BPTB) autograft, and 3) allograft. An autograft refers to tendon material taken from the patient and used to replace the torn ligament. An allograft is tendon graft material from a donor bank.

Although the overall infection rate was low (0.48 per cent), the fact that there was an obvious and statistically important difference between the autografts is very significant. In more simpler terms: graft choice does make a difference. There was no apparent difference in the infection rates between autografts and allografts. These findings support (agree with) other previous studies but now provide the added information of how often this happens.

Some additional details from the study also included the fact that there was a 2:1 ratio of deep (deep soft tissue or joint) to superficial (skin only) infections. The superficial infections occurred early on (first month after surgery). Deep infections were more likely to develop up to one year after the procedure.

Further analysis of all the data also revealed that in most cases, hamstring tendon grafts were the source of both superficial and deep infections. Staphylococcus bacteria accounted for half of the deep and three-fourths of the superficial infections. More obese patients (higher body mass index) had a greater chance of developing a superficial infection. The reason for this is unknown but may be linked with the need to remove more soft tissue in larger patients.

What is behind this observed increase in superficial and deep infections associated with hamstring tendon grafts used for ACL reconstruction? There may be more than one possible avenue for this occurence. The authors suggest the following possibilities:

The graft tissue is contaminated during the harvest procedure.

The graft tissue is contaminated after harvest but while it is being prepared for use.

Hamstring tendon grafts take longer to prepare giving more time for possible contamination during graft preparation.

Hamstring grafts require the use of a multifilament suture, which could be the source of the bacteria.

If the graft or hardware used to fix the graft in place comes in contact with the skin, then contamination is more likely.

The tools (e.g., screwdriver) used to insert the screws that hold the graft in place could be an external (environmental) source of contamination.

The purpose of this study was not to identify risk factors for infection after ACL reconstruction. The authors’ intent was to determine the incidence of such infections and that was accomplished successfully. They suggest future studies to evaluate the many possible risk factors and determine the source and cause of infections. Although the infection rate is fairly low, the results of infections can be devastating to the patient. Preventing infections is still an important goal.

Osteochondral Scaffold: A Valid Treatment for Knee Osteochondritis Dissecans

In this study, orthopedic surgeons from Italy explore the use of a minimally invasive, one-step osteochondral scaffold to repair damage to the surface of the knee joint. The level of evidence is low (rated four on a scale from one-to-four) because it is a case series. But the information about results is still valuable when a new type of treatment is introduced.

The condition being treated is known as osteochondritis dissecans or OCD. This is an acquired injury from repetitive microtrauma. A lack of blood supply to the damaged area causes separation of the first two layers of the knee joint: the cartilage that lines the joint (articular cartilage) and the subchondral bone (bone just under the cartilage).

The end-result is a hole (referred to as a “lesion” or “defect”) in the knee joint cartilage that goes down to the bone. The defect is on the bottom of the femur (thigh bone) where the femur comes in contact with the tibia (lower leg bone). Instability of the articular cartilage causes pain, swelling, and loss of knee motion and knee function. Left untreated, uneven contact of the joint eventually causes further degeneration of the joint and arthritis.

The condition affects active teenagers and young adults most often. The patients in this study ranged in ages from 18 to 33. The most effective treatment (especially for large lesions) is surgical with a wide variety of procedures currently in use. The goal of surgery is to restore the joint surface to as normal as possible (anatomically).

Placing collagen tissue (the basic building block of cartilage and bone) into the defect is one of the techniques under investigation. In this study, a three-layer scaffold made of type I collagen fibers was placed in the defect. The surgical procedure involved removing the damaged bone, placing aluminum foil inside the hole to form a template, and then implanting the hole with the exact size of collagen graft. An on-line video is available for anyone who would like to see the procedure.

The idea was to stimulate the body to fill in the scaffold as part of the natural healing process. Did it work? Let’s look at the results two years later. Outcome measures used included: patient symptoms, knee range-of-motion, status of knee ligamentous stability, and return-to-sport. MRIs were also taken to assess the actual changes at the joint. Patient symptoms and function were compared against the MRI findings.

All measures of function improved for each patient over the two-year period. In fact, continued improvements were observed between year one and year two. The MRI showed complete filling of the defect in three-fourths of the patients by the end of the first year. There was complete integration of the graft by the end of the second year. But the subchondral bone was never fully restored and changes such as edema, cysts, and sclerosis were seen in two-thirds of the patients.

Despite what might seem like a lack of complete healing response with a return to normal joint integrity, the majority of patients had no symptoms and were able to function fully. Not only that, but the size of lesion was not an issue. Even the largest defects responded well to this treatment. A few patients (three) had some minor reactions to the treatment with knee swelling and stiffness but there were no failed procedures among the group.

The authors concluded that the use of collagen-hydroxyapatite osteochondral scaffold can be beneficial to patients with all sizes of lesions from knee osteochondritis dissecans (OCD). With the typical poor prognosis of untreated OCD, finding a successful treatment with minimal adverse effects is exciting news. This procedure has the added benefits of being a simplified, one-step, and minimally invasive surgical approach.

Value of Total Knee Replacements to Society

With more and more adults getting knee replacements, analysts are taking a closer look at the costs versus benefits to the individual patient and to society. Society can include employers and insurance providers (payers). You are a part of “society” in this sense if you pay taxes that finance Medicare, a principal payer of many surgical procedures in older adults.

There are three ways to evaluate the “cost” of surgical versus conservative care for knee osteoarthritis: 1) direct costs, 2) indirect costs, and 3) quality of life measures. Direct costs include any and all medical expenses for any treatment provided.

Indirect costs refer to lost wages when the patient can no longer work full-time or can’t work at all and to disability payments paid out over time. Indirect costs to the employer occur due to employee absenteeism and lost productivity. Quality of life is measured based on patients’ perception of pain, motion (loss of motion), function (loss of function), and level of disability.

This is the first study to take a closer look at all costs associated with knee replacement versus conservative care (without surgery) for patients with end-stage (severe) osteoarthritis. They studied the U.S. population (ages 40 and older) who received a total knee replacement in the year 2009.

After reviewing and analyzing all the data collected, the research showed that there was a 12 billion dollar savings to society in one year (2009) for the 600,000 total knee replacements that were done. They concluded this represents a significant amount of money attributed to extra work years (and increased income) made possible by the surgery.

This information will be very helpful if and when insurance companies and other third party payers suggest finding ways to limit who qualifies for a total knee replacement (referred to as coverage restrictions). Likewise, if higher copayments are proposed, research like this comparing costs and estimating savings to society is very important.

Other factors affecting lifetime savings associated with total knee replacements include age and work status. Younger patients have longer to work and earn money. The study showed that patients in the youngest category (40 to 44 years old) could potentially (each) earn $174,364 more over a lifetime by having the surgery compared with the over 80 age group.

Older adults also had higher total medical costs regardless of whether they had surgery or were treated conservatively. But the cost of a total knee replacement for severe, limiting osteoarthritis in the older group was also offset by fewer health problems (heart attacks, strokes) compared with patients of the same age with equal joint disease who did not have knee replacement surgery.

In a parallel analysis, work status (receiving disability, retired, or working part- or full-time) was equally important in calculating cost to society. As you might expect, those individuals who continue working and earning income generate greater savings compared with patients who receive disability checks each month.

In conclusion, total knee replacements are cost-effective when viewed from a societal perspective. This study showed a positive net benefit to society in terms of cost savings for all age groups but especially those younger than 70 years old (and especially for adults in their early 40s). Quality of life is improved with surgery, which can also translate into dollars saved. Payers and policy makers should take this information into consideration when making plans to restrict access to knee replacement surgery.