Healthy Living Series | Orthobiologics

December 10th, 2019 at 6:00pm
at the Hughston Foundation Auditorium

 

“Orthobiologics”

 

Kurt Jacobson, MD, FACS; David Rehak, MD; and Champ Baker III, MD
There are natural, minimally invasive choices for managing orthopaedic conditions.

 

Interested in learning more about adipose, stem cells, platelet rich plasma (PRP) and growth factors?

Come to a presentation & question session on how these treatments can help.

Light hors d’oeuvres will be served.

 

To register for this FREE educational event, please contact Belinda Klein at
706-494-3326 or bklein@hughston.com.

 

 

Dry Needling: What You Should Know

Dry needling, also known as intramuscular stimulation, is the use of solid filiform or “noninjection” needles to stimulate specific reactions in an area of muscle tissue and the surrounding fascia, or membrane, in order to alleviate pain. Dry needling has been a viable treatment technique for myofascial (involving the muscle and surrounding connective tissue) pain since the 1940s. At that time, Janet G. Travell (1901-1997), a physician-researcher who specialized in treating patients with myofascial pain and served as President John F. Kennedy’s personal physician, discovered that dry needling is as effective as “wet needling”—the use of hollow-core hypodermic needles to inject a fluid, such as a local anesthetic or saline solution—in relieving myofascial pain. Thanks largely to researchers like Dr. Travell, the use of dry needling has become more popular, particularly in the world of physical therapy.

 

How does dry needling differ from traditional acupuncture?
Dry needling neither shares acupuncture’s philosophy of treatment, which is based on traditional Chinese medicine (TCM) and aimed at treating the underlying causes of the pain, nor is it generally performed by an acupuncturist. (A recent Hughston Health Alert article entitled, “Acupuncture and Orthopaedic Pain Management,” Volume 27 (1), reviews the current traditional Chinese style of musculotendinous acupuncture used here in the West.) In contrast to TCM, dry needling is based on contemporary knowledge of musculoskeletal and neurological anatomy, pathophysiology, and evidenced-based research. Unlike TCM, dry needling targets discrete, hypersensitive spots in the fascia of the skeletal muscle known as trigger points (a term coined by Dr. Travell in 1942). Upon palpation, trigger points may feel like nodules or knots in the muscle fibers within a taut band. Large muscles may contain clusters of trigger points. Stimulating trigger points causes local tenderness and typically reproduces the patient’s pain. It may also elicit pain in other parts of the body, a phenomenon known as referred pain.

While dry needling is distinct from traditional acupuncture, it does employ similar needles and techniques. Additionally, the trigger points of dry needling often overlap with acupuncture points as these are closely related to nerves and motor points in muscles.

 

Needles
Dry needling uses extremely fine, solid, stainless steel filiform needles that vary in length. The size selected for use depends on the depth of the tissue being treated. Needles should never be reinserted into a patient. Instead, single-use, presterilized, individually packaged disposable needles are recommended.

 

Technique
To begin insertion, the needling location is palpated and the needle placed at the specific point. Next, using a plastic guide tube, it is tapped into place; the guide tube is then removed, and the needle inserted. Once a needle is in place, the practitioner can manipulate it and adjust its depth (Fig.). Most patients describe minimal to no pain with this technique and typically report the dry needling sensation as a “light pressure.” As with most types of medical treatments, dry needling is not without risks, but the application of good palpation skills and proper technique minimize these. Possible side effects from dry needling include soreness and bruising that can last from a few hours to a couple of days.

 

Who performs dry needling?
Dry needling is usually performed by a physical therapist. Not all therapists, however, can offer their clients dry needling. In most states, a practitioner must have a certain amount of education and training in dry needling before he or she is certified to treat patients. Depending on state laws and practice acts, sometimes chiropractors, medical doctors, osteopathic physicians, naturopathic physicians, acupuncturists, and other practitioners are also trained in dry needling.

 

One tool among many
Therapists perform an initial evaluation and then use the findings to determine the proper type of physical therapy treatment for the individual patient. While dry needling can be an important part of therapeutic treatment, it is only 1 of several modalities physical therapists might use to treat myofascial pain or musculoskeletal conditions. In fact, dry needling is rarely used as a stand-alone treatment, but is usually incorporated into a regimen which can include manual soft tissue mobilization, neuromuscular re-education, posture correction, range of motion exercises, stretching, and massage, as well as ultrasound and electrical stimulation.

 

How does dry needling relieve pain?
The precise mechanism that makes dry needling an effective intervention for musculoskeletal pain remains unknown. Nevertheless, several theories have been formulated to explain its effectiveness by examining the response of the neuromuscular system to the introduction of a needle into the body. There are 3 types of responses: mechanical, chemical, and neurophysiological (having to do with the functions of the nervous system).

 

Mechanical theory
Mechanically, when a needle is inserted into the body, it damages tissue, creating a controlled lesion. The body then produces an inflammatory response to this lesion and immediately begins to work to repair the damaged tissue as well as any previous lesions in the area.

 

Chemical theory
Dry needling has been shown to increase the amount of chemicals at the nerve ending. The release of some of these chemicals is thought to over stimulate the nerve. The hyperexcited nerve then elicits a local twitch response (LTR) from the muscle —a visible, involuntary spinal cord reflex in which the muscle fibers contract and cause a sensation much like a cramp. The LTR works to stabilize or reset the chemical balance at the nerve ending, causing any spontaneous electrical activity to subside. This in turn “resets” the muscle and releases the local trigger point.

 

Neurophysiological theory
From a neurophysiological standpoint, dry needling has been shown to facilitate the release of chemicals that mediate the transmission of pain signals. Most likely, as it elicits LTRs, dry needling also activates the body’s production of endogenous opioids or pain-relieving, sleep-inducing substances, such as endorphins.

 

Conditions treated
Regardless of how or why it works, clinical studies comparing the effects of dry needling with placebo treatments have demonstrated that it reduces pain and improves musculoskeletal function. It has proven effective in alleviating such conditions as spinal pain, tennis elbow, plantar fasciitis, Achilles tendinitis, and other tendinopathies. Moreover, dry needling can ease muscle spasms, muscle or band tenderness and tightness, and some hypertonic (having an abnormally high degree of tone or tension) muscle conditions. It can also help to control pain following trauma, sports-related injuries, and nonsurgical interventions. Overall, it has been shown that when dry needling is incorporated into a treatment plan, musculoskeletal function is restored much more quickly. Generally, patients can expect to see positive results from dry needling after 2 to 4 sessions.

 

More research and more availability ahead
Despite good clinical results, many of the studies published on dry needling have lacked strong evidence because they contained small sample sizes, had high dropout rates, or were not randomized. Additional investigation and more controlled studies are thus needed to determine and document the true short- and long-term effectiveness of dry needling for various conditions.

As dry needling is still a relatively new tool, some physicians are unaware that it is available to patients.
After further research has been done, dry needling should become more widely accepted as a form of physical therapy and more frequently offered as a viable treatment option.

 

Author: William Kuerzi, PT | LaGrange, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 28, Number 2, Spring 2016.

 

 

Orthopaedic Imaging

If you have a bone or musculoskeletal problem, your physician will usually begin the diagnostic process with x-rays. X-rays are an excellent screening tool for visualizing bone pathologies, such as fractures or degenerative joint disease. In many instances, however, either the presence or absence of findings will warrant a closer look, prompting your attending physician to order a computed tomography (CT), magnetic resonance imaging (MRI), or nuclear medicine scan. Each of these scans offers different advantages and disadvantages for you as a patient, and the type of imaging study or studies your physician orders will depend largely on your symptoms and health history.

 

Computed tomography

The word tomography comes from the ancient Greek roots, tom-, meaning a cutting or slice, and –graphy, meaning imaging or writing, and thus refers to the imaging of internal cross-sections of the body. The term computed tomography (CT) or, sometimes, computed axial tomography (CAT), refers specifically to combined computer-processed x-ray images of internal cross-sections of the body taken from different angles. If you suffer an acute trauma, your doctor will typically order a CT scan to rule out fractures and dislocations. Although a CT scan may be recommended for you largely because of its ability to evaluate bony structures, special studies, such as a CT arthrography (joint imaging) or CT myelography (spinal cord, nerve root, and other soft tissue imaging), may be ordered to provide details about your soft tissue. By injecting a radiocontrast agent or medium (typically an iodine or barium compound) directly into the joint or spinal canal to make internal structures and bodily fluids more visible on imaging, such studies can offer detailed pictures.

One advantage of a CT scan over other types of scans is how quickly it can be performed. During a CT scan, a high-powered x-ray tube rotates around your body to generate the images. This generally takes only a few minutes and can be performed with a single breath hold. Another advantage of CT imaging is that it is safe even if you have had a metal device or certain types of hardware implanted in your body. In fact, if this is the case for you, your doctor should order a CT scan rather than other imaging modalities.

The major disadvantage of having a CT scan is that it uses ionizing radiation (the emission of electrical charges and electromagnetic waves) to produce images and in the process exposes you to a higher dose of radiation than a conventional x-ray. Radiation exposure can harm cellular structures and processes and can directly or indirectly affect DNA. However, as CT scans are now performed more quickly, the amount of radiation to which you are exposed is less than you would receive as an airline passenger on a long flight. Furthermore, advances in CT scanning have resulted in higher resolution images and increased comfort for you as a patient.

 

Magnetic resonance imaging

Unlike CT scans, which use x-rays, MRI scans use powerful magnetic fields along with radio frequency pulses to produce detailed images of bones as well as soft tissues such as muscles, tendons, ligaments, and cartilage. Since the images are produced by a magnetic field, you are not exposed to radiation, and this constitutes an advantage over a CT scan.

Additionally, MRI scans are superior for soft tissue imaging. As with soft tissue CT scans, administering contrast agents or mediums (usually a compound with the ability to alter the magnetic properties of nearby hydrogen atoms) through an IV has been found to enhance imaging. Moreover, the contrast setting of an MRI can be changed to highlight different types of tissues and any subtle differences between them. The imaging plane can also be changed without moving the patient.

The chief disadvantage of an MRI is that its powerful magnetic field can prove harmful if you have certain metal devices in your body such as pacemakers, cardiac monitors, spinal cord stimulators, and some types of surgical clips. Another disadvantage of this type of imaging is the time required to scan—typically around 30 minutes. Additionally, when you have an MRI, you are placed in a cylindrical tube that could make you feel uncomfortable or claustrophobic. Open MRI scanners are available, but their magnetic field is significantly weaker, and, consequently, they produce much less detailed images. Overall, despite their disadvantages, including the increased cost compared with CT scans, MRIs are still more commonly performed when a high degree of soft tissue detail is needed.

 

Nuclear medicine

Nuclear medicine refers to a type of noninvasive, painless (apart from the placement of an IV) imaging procedure that helps physicians diagnose and evaluate a host of medical conditions involving bones or soft tissue. As a diagnostic tool, nuclear medicine has been around for 60 years—longer than CT or MRI. In contrast to both CT and MRI scans, nuclear medicine imaging uses radioactive materials called radiopharmaceuticals or radiotracers. These drugs, which can be taken either orally or intravenously, contain radioactive isotopes (variants of elements that emit energy in the form of gamma rays and decay quickly). Consequently, with nuclear imaging, unlike x-rays and CT scans, the radiation that helps produce the images is emitted by your body rather than externally generated. This radiation can then be detected by a specialized camera or imaging device. From the data gathered, the device produces scintigrams (recordings of the scintillation or flashing from the radioactivity) that yield images of your bones. Areas that take up more or less of the radiopharmaceutical show up as either brighter or darker than normal on a scintigram and may indicate abnormalities in your bone.

The primary drawback of nuclear medicine imaging is that it exposes you to ionizing radiation. You could also have an allergic or injection site reaction to the radioactive material. On the other hand, nuclear medicine imaging offers a huge advantage over other types of scans: rather than merely picturing structures, nuclear scans can show how different areas or organs of the body are functioning on the molecular level. This means they have the potential to detect disease in its earliest stages. For instance, a bone scan can often pick up abnormalities inside your bone that may indicate cancer much earlier than a normal x-ray. It can also reveal a tiny fracture before it can be seen on an x-ray.

 

Understanding your test

If you go to your doctor with a bone or musculoskeletal problem—for example, a stress fracture, torn tendon, or even complications from a hip or knee replacement—he or she may order a CT, MRI, or nuclear scan. The proper imaging modality will depend on your particular situation. Thus you should feel free to discuss any questions or concerns you may have about the diagnostic process or a particular test with the ordering physician or a radiologist (an expert at reading such images). You may also want to gather information on your own ahead of time. A website dedicated exclusively to MRI safety can be found at www.MRIsafety.com. Informing yourself about different types of diagnostic imaging is important so that you can feel confident that your doctor is prescribing the most appropriate imaging modalities for your condition and that the testing you have performed is safe.

 

Author: Cameron C. Kersey, MD | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 28, Number 2, Spring 2016.

 

 

Staph Infections of the Skin


The bacterium Staphylococcus aureus—staph for short—is so named because when viewed through a microscope, it is berry-shaped and exists in grapelike clusters that have a golden yellow pigment. The root staphyl(e), originally from ancient Greek, refers to a bunch of grapes; coccus, from Latin, refers to something spherical, like a berry; and aureus, also Latin, means golden. Staph is a gram-positive bacterium, meaning that it stains purple when tested because it has a single outer membrane rather than many, making it more permeable to antibiotics (Fig.). Staph infections are therefore often successfully treated with antibiotics; however, some strains are resistant to antibiotics and, consequently, more difficult to treat. Staph is also highly contagious and can be spread through hand-to-hand contact, airborne transmission, or contact with an object. Although most staph infections occur on the skin, they can also occur in the nasal and sinus passages, mouth, anus, and genital areas. If you have a fresh wound that comes in contact with an infected person or object, a staph infection can easily erupt and will often present itself as a boil or abscess (Box 1).

 

Are you at risk for a staph infection?

If you suffer from influenza, diabetes mellitus, and pulmonary (lung) disorders, or your immune system is compromised in any way, you are more likely to contract staph infections of the skin. Additionally, if you become a hospital patient or are an athlete, you may be more frequently exposed to staph inside a healthcare or athletic facility.

Hospitals
Staph infections are commonly found in hospitals and healthcare clinics

where they can constitute a major problem. For example, if proper sterilization techniques are not used, staph can easily spread throughout a hospital or healthcare facility. Additionally, humans tend to harbor staph bacteria in the mucous membranes of the nose and sinuses. As a way to prevent infection, some hospitals and healthcare clinics take nose swabs before surgery. If the swab comes back positive for staph, you will be treated with antibiotics before your doctor proceeds with surgery. Other hospitals have patients cleanse their entire skin surface with a chlorhexidine wipe and put Betadine gel in their nose the morning of surgery.

Athletic facilities
Likewise, athletic facilities, such as health clubs and gyms, including weight rooms, wrestling rooms, and locker rooms, are all places where staph bacteria can grow and you can easily pick up an infection. Staph bacteria can be hard to destroy and can live on unclean equipment and facility surfaces long enough to be transferred to anyone who touches them. If you have an open wound on your body, this makes it easy to contract a staph infection. Likewise, if you have a cut that is not covered or treated properly and it becomes infected, the bacteria could easily spread to other people or to objects. As an athlete, frequent close contact with other athletes and poor locker room hygiene, such as the use of unwashed towels and uniforms, can make you susceptible to contracting staph infections (Box 2).

 

Recognizing staph infections of the skin
In the initial stages, a staph infection often manifests as a small lesion that may look much like a pimple or mosquito bite. As the lesion enlarges, it becomes painful and inflamed. It may also contain pus. If the infection continues to spread, you may experience a mild fever. Skin infections caused by staph include boils, impetigo, and cellulitis.

 

A common type of staph infection
A common and well-known form of staph is methicillin-resistant Staphylococcus aureus (MRSA). This is a specific strain of the bacterium that is resistant to many of the antibiotics used to treat staph infections. Once a staph infection is classified as MRSA, it is considered much more dangerous because without effective antibiotic treatment it can quickly worsen. The Centers for Disease Control states that approximately 100,000 people contract and receive treatment for MRSA each year.

 

Treating staph infections
If you are worried that you may have contracted a staph infection of the skin, it is important to see your doctor promptly. The sooner the wound can be tested for bacteria the better. If not treated properly, a staph infection can spread quickly within the body and be transmitted to others.

The first route of treatment of the infection is usually antibiotics. You should receive a course of antibiotics as well as instructions on how to cover the wound with antibiotic ointment and a bandage. Your staph infection may return if it is not fully treated the first time or if it becomes antibiotic resistant. If the staph infection does return, your doctor may prescribe a second course of antibiotics. If the infection still does not clear up, you may need to be hospitalized for treatment with a more aggressive antibiotic regimen. At worst, you may need surgery to remove the infected tissue completely.

 

Keeping staph in check
Staph is a highly contagious infection that is spread primarily through hand-to-hand contact or through the air and can occur when you have a fresh wound that comes in contact with an infected object. If you start experiencing redness, swelling, and heat around a wound, you should see a physician right away and be tested for staph and put on a course of antibiotics, if appropriate. You should also receive instructions on how to keep a wound clean and covered. If you are an athlete, it is especially important to practice good hygiene and to keep all sporting equipment, clothing, and workout areas clean. To avoid a potentially dangerous situation and to shield those around you, it is crucial to act upon what may be a staph infection at the first signs of symptoms.

 

Authors: Marissa Turturro, ATC, and Amanda Guethlein, ATC | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 28, Number 2, Spring 2016.

 

Rotator Cuff Tears

The rotator cuff is a group of muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) and tendons (tissue connecting muscle to bone) that surrounds the shoulder joint (Fig). This group of muscles provides stabilization while also allowing movement, which is why the shoulder is one of the most flexible joints in the body. Interestingly enough, many patients with rotator cuff tears have no symptoms at all, while others complain of pain and weakness in the shoulder. A rotator cuff tear can range from small to large in size, it can be a partial tear in 1 of the muscles, or it can be a partial or complete tear of a tendon. Almost 1 out of 3 people over the age of 60, and 2 out of 3 people over the age of 70 have full thickness rotator cuff tears. Depending on the severity of the tear, there are various treatment options, which include nonoperative management and shoulder arthroscopic surgery.

 

 

What causes a tear?
The rotator cuff can become injured in a number of ways. Most commonly, the tear is due to chronic muscle and tendon degeneration that comes with aging. Additionally, they often occur in conjunction with a shoulder dislocation in patients over 40 years old. You can injure your rotator cuff by falling on an outstretched arm or develop an injury over time doing repetitive activities at work or while playing a sport. Another possible mechanism is from impingement (weakening and tearing at the tendons) of the rotator cuff on the acromion (the bone right above the shoulder joint). The acromion process can develop bone spurs that can rub on the rotator cuff tendons, causing impingement.

 

Risk factors
There are several risk factors associated with rotator cuff tears, but advanced age is one of the most significant. Others include having a rotator cuff tear on the other shoulder, smoking, family history, poor posture, high cholesterol, history of trauma, and occupations demanding heavy labor and repetitive movement.

 

Seeking medical advice
When to seek medical advice can be a difficult question to answer since patients have a wide range of how much pain and dysfunction they can stand before it triggers a visit to the doctor’s office. Where some patients develop a small discomfort in their shoulder and immediately see their doctor, others wait until their pain is unbearable and they have lost most of the function in their shoulder. Certainly, any amount of pain and discomfort, weakness, and loss of shoulder function should warrant a visit to a sports medicine or shoulder-trained orthopaedic physician.

 

Screening and diagnosis
Your physician will examine the shoulder, moving it through various positions and maneuvers in an attempt to localize the problem. Radiographs or x-rays, will also be obtained to evaluate for any bony involvement. Depending on the length of time the problem has been going on, or if there has been a recent traumatic injury, the physician may decide to order magnetic resonance imaging (MRI, a scan that shows the bones, muscles, tendons, and ligaments) of the shoulder. Additionally, your physician may also decide to perform an injection into the subacromial space (the space between the rotator cuff muscles and the acromion) (Fig). This is not only a treatment option, but it can also provide the physician with valuable information regarding your diagnosis by whether you experience pain relief or not.

 

Treatment
Most rotator cuff tears can be initially managed with nonoperative treatment. These include physical therapy, anti-inflammatory medications, and subacromial corticosteroid injections. It is important to consider patient expectations and symptom severity when deciding on nonoperative treatment as this is different for every patient.

If the injury is severe or an acute tear following some sort of traumatic episode, such as a fall or shoulder dislocation, or if nonoperative management is not working, the physician may recommend surgery. Surgery is performed arthroscopically (using a small camera to look inside the shoulder joint). This is typically done using 3 or 4 small incisions around the shoulder. The surgeon will examine the shoulder anatomy and clean up any loose and frayed tissue, remove any bone spurs, and then repair the tear depending on the appearance of the rotator cuff and the size of the tear.

The surgery usually takes an hour to an hour and a half depending on what needs to be done. After surgery, your shoulder will be placed in an abduction shoulder brace (a sling that holds the arm out to the side) and you will be given specific instructions that help the healing process and encourage a positive outcome.

 

Postoperative rehabilitation
Postoperative protocols for rehabilitation vary by physician; however, most exercise treatments follow the same general principles. Initially the shoulder is kept immobilized. Then a period of passive range of motion exercises follows, which mean that your arm is moved without you exerting any effort. Then active range of motion begins, which will progress to a resistance-training program.

 

Outcomes and complications
A rotator cuff repair can offer predictable success with a long track record of pain relief and patient satisfaction. Medical literature shows excellent outcomes in patients with partial and full thickness tears.

Failure to heal is the most common cause of a failed rotator cuff repair. Patients at risk for failure include those who are 65 years of age and older, smokers, diabetics,
and those who have large size tears, muscle atrophy (shrinking), and those who do not follow the surgeon’s postoperative rehabilitation plan. More rare complications include injury to nerves in the shoulder, infection, and stiffness. Often, postoperative stiffness can be managed with physical therapy.

 

Don’t shoulder the pain alone
Rotator cuff tears are common in the aging population and can debilitate patients with extreme pain and functional limitations. For most circumstances, conservative treatment should be attempted first as many patients will respond positively. Surgical treatment has shown to have excellent results and should be weighed between the patient’s pain and function, as well as avoiding progression of the tear. If you have shoulder pain, see an orthopaedist who specializes in the shoulder. A speciality-trained shoulder physician will quickly and accurately diagnose your problems and get you on the road to recovery.

 

Author: Roman I. Ashmyan, DO | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 31, Number 1, Winter 2019.

 

Complex Regional Pain Syndrome

In the 16th century, King Charles IX experienced endless pain and contractures after he underwent a surgical procedure. Ambroise Pare (known as the father of modern surgery) recorded the King’s treatment, which is thought to be the earliest documented description of complex regional pain syndrome (CRPS).1 Formerly known as reflex sympathetic dystrophy (disorder of the sympathetic nervous system) and causalgia (affecting a peripheral nerve), it was not until 1994 that the International Association for the Study of Pain renamed these pain syndromes as CRPS Type 1 and CRPS Type 2, respectively.2

 

Who does it affect?
CRPS is a rare and debilitating disease that affects less than 2% of individuals in the United States. Race is not a factor, but females are affected more than males, and the peak age of patients is 40 to 49 years. Additionally, the upper extremities are affected more often than the lower extremities.2

 

What are the symptoms?
CRPS patients experience chronic pain with sensory and motor symptoms in their limbs. With CRPS, there is usually a damaging or inciting event that causes injury, such as trauma, surgery, or a period of immobilization. The difference between the 2 types is that Type 1 does not have a distinctive injury to a nerve, whereas patients with CRPS Type 2 have a known nerve injury. To help diagnose CRPS, the Budapest criteria (Table) were established in 2003. In patients who have continuing pain that is disproportionate to any inciting event, they must report 1 symptom in 3 of the 4 following categories: sensory, motor/trophic, vasomotor, sudomotor/edema.1 The patient must also display at least 1 sign at the time of evaluation in 2 or more of the categories. Lastly, there cannot be another condition that would account for the degree of pain and dysfunction that the patient is experiencing.

There are 3 stages of CRPS: acute, subacute, and chronic.2 The acute stage lasts 3 months. During this stage patients usually have a burning type pain, swelling, skin redness, increased sweating, and decreased range of motion. After 3 months, the patient enters the subacute stage. During this stage patients have continued severe pain, swelling, skin dryness, and paleness or bluish coloration of the skin. After 12 months, the patient progresses to the chronic stage that can last for multiple years or even become permanent. In the chronic stage, the patient’s pain is variable and can continue to be severe or it may subside. The patient’s skin is dry, shiny, and cool to the touch. Also, since the patient has not been using their extremity, the underlying bones can develop osteoporosis (a disease that weakens bones).3

 

How is CRPS diagnosed?
There are no specific laboratory studies that make the diagnosis of CRPS; however, it is imperative to obtain laboratory studies so that other disease or disorders can be excluded as the cause of the patient’s symptoms.2 Imaging studies that are useful include radiographs (x-rays) and bone scans (an imaging test that helps diagnose bone disease). Since CRPS Type 2 involves a known nerve injury, a nerve conduction study can provide useful information as well.4

 

How is CRPS treated?
The best treatment for CRPS is to use a multidisciplinary team approach to alleviate the patient’s pain and help the patient regain function of the extremity.1 For example, a pain specialist helps control the patient’s pain using medications and injections. A surgeon is needed for procedures that help control pain and regain extremity function. A primary care physician can help with the patient’s pain control as well as helping with other symptoms, such as swelling, inflammation, and depression. Physical therapists and occupational therapists are critical in improving the functional outcome of the affected extremity with range of motion exercises and other modalities.5

 

Getting help
CRPS results in debilitating pain and significant loss of function in the extremities. In order to improve patient outcomes, CRPS should be recognized early on and treatment initiated as soon as possible. Pain specialists, surgeons, physical therapists, and other healthcare providers each play a role in helping the patient get back to a normal routine. If you are experiencing chronic pain, talk to your doctor, getting help is the first step toward a pain-free life.

 

Author: Mudassar A. Khan, DO | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 31, Number 1, Winter 2019.

 

References
1. Sebastin SJ. Complex regional pain syndrome. Indian Journal of Plastic Surgery. 2011;44( 2):298-307.
2. Goh EL, Chidambaram S, Ma D. Complex regional pain syndrome: A recent update. Burns & Trauma. 2017;5(1):ecollection. doi:10.1186/s41038-016-0066-4.
3. Baron R, Binder A. Complex Regional Pain Syndromes. Baron R, Binder A, Pappagallo M, editors. In: The Neurological Basis of Pain. New York, NY: McGraw-Hill; 2005:359-378.
4. Harden RN, Oaklander AL, Burton AW, et al. Complex regional pain syndrome: Practical diagnostic and treatment guidelines, 4th ed. Pain Medicine. 2013;14(2):180-229.
5. Stengel M, Binder A, Baron R. Updates on the diagnosis and management of complex regional pain syndrome. Advance Pain Management. 2007;1(3):96-104.

 

 

Ice Skating Injuries

Recreational ice skating and related sports, such as hockey, are popular winter activities. Regular participation in ice skating has shown to help individuals maintain balance as they age, but the activity is not without risk. About 1 in every 700 ice skaters will experience an injury,(1) and the average age of those injured is 33 years old.(2) Most incidents occur during falls on the ice, with inexperience and the slippery surface adding to the risks. Before you head to the rink, you should be aware of common injuries, how they occur, and understand what treatments are available.

 

Concussion
Head trauma only accounts for about 0.5% of ice skating injuries,(1) but the rate increases significantly with participation in ice hockey. Concussion is a traumatic injury to the brain that can occur after a blow to the head, face, or neck (Fig. 1). When you experience a concussion, your motor skills, coordination, balance, and cognitive abilities may be impaired. Concussions range in severity; which means it can be so slight you may not know that you have a concussion or it can be so severe you are rendered unconscious. In addition to the severity, more than 1 concussion can cause serious effects. If you have sustained multiple concussions, you have an increased risk of another and the cumulative effect can be permanently damaging or deadly. After a blow to the head, you should seek immediate medical attention if there has been a loss of consciousness, continued confusion, worsening symptoms, weakness, numbness, slurred speech, vomiting, seizure, or blood or clear fluid coming from the nose or ears.

Symptoms from concussion can last from a few days to several months, and include: headache, dizziness, nausea, trouble paying attention, memory problems, irritability and depression. If you have sustained a concussion, you should stop sports participation immediately and avoid further at-risk activities until all symptoms have resolved. While recovering from a concussion, stimulation should be minimal, which means reducing screen time, avoiding loud music and noise, and limiting cognitive tasks.

 

Distal radius fracture
Almost all fractures sustained in ice skating occur in the upper extremity, with fractures of the distal radius (wrist) being the most common of these.(1,2) Wrist fractures often occur during a fall on an outstretched hand, resulting in immediate pain and deformity at the injury site (Fig. 2). Once you present to an emergency department, doctors will often reduce (align the fracture) and place a splint to hold the bones in place.

Further treatment will be determined with your orthopaedist and depends on many factors such as: if the break includes the wrist joint, how many fracture lines you have, or if a splint can hold the bone fragments in the correct position. Closed reduction and percutaneous pinning or CRPP, (a procedure to align the bone using metal pins through the skin to hold the fracture while the bone heals), or open reduction with internal fixation (ORIF, a procedure to hold the fracture with metal plates and screws under the skin) are 2 treatment options that offer good results. Particularly in women, a distal radius fracture can be a sign of decreased bone mineral density;(3) therefore, you should ask your doctor if further testing, such as a DEXA (dual energy x-ray absorptiometry, a type of bone scan) scan is needed.

 

Radial head and neck fractures
Another injury that can occur from a fall on an outstretched hand—radial head and neck fractures—occur about 10% less often than distal radius fractures.(2) The radial head is the portion of the radius that helps form the elbow joint, with the radial neck located just below it. Unlike distal radius fractures, these injuries rarely result in a noticeable deformity, with patients mainly complaining of severe elbow pain, swelling, and reduced elbow motion (Fig. 3).

The majority of these fractures can be treated without surgery, with an emphasis on regaining elbow motion early to avoid permanent stiffness. You may need surgery if the fracture involves multiple fragments or if the fragments have moved. Surgical treatments often involve holding the bone in position with metal plates and screws while the fracture heals, or replacement of the radial head with a metal prosthesis for more severe injuries.

 

Ice hockey
Ice hockey is a much more physical and high-risk activity than recreational ice skating. Hockey resulted in the highest injury rate at the 2010 Olympics, with up to 35% of participants experiencing some amount of missed playing time.(4) Since there is an increased risk of contact, common injuries in ice hockey involve the shoulder, hip, thigh, and knee rather than the elbow and wrist. Many of these injuries can be treated nonsurgically, with immobilization, rest, compression, and therapy. If the injury is severe or recurrent, surgery is sometimes needed.

Your best chance at avoiding an injury is to wear properly-fitted equipment, such as helmets, shoulder pads, hip pads and hockey pants, and skates. You should also properly maintain the equipment and replace it as it becomes worn or damaged. Furthermore, emphasis on playing “heads up” hockey with attention paid to surroundings and avoiding hard contact with another player can help reduce injury rates in this sport.

 

Protect yourself
Ice skating is a popular activity that has numerous health benefits, but the sport is not without risks. Understanding common injuries and taking proper precautions to avoid them can help you enjoy these activities without incident. You can reduce the risk or avoid trauma all together by wearing snug-fitting skates with a straight back over the blade, and by using commercial wrist protectors. You can purchase affordable protective gear at most sporting goods stores.

 

Author: Timothy R. Beals, DO | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 31, Number 1, Winter 2019.

 

References:
1. Kelsall NKR, Bowyer GW. Injuries sustained at a temporary ice-skating rink: Prospective study of the Winchester experience 2007–2008. Injury. 2009;40(12):1276-1278.
2. Barr L V., Imam S, Crawford JR, Owen PJ. Skating on thin ice: a study of the injuries sustained at a temporary ice skating rink. International Orthopaedics. 2010;34(5):743-746.
3. Rozental T, Deschamps L, Taylor A, Al E. Premenopausal women with a distal radial fracture have deteriorated trabecular bone density and morphology compared with controls without a fracture. Journal of Bone and Joint Surgery, American. 2013;95(7):633-642.
4. Laprade RF, Surowiec RK, Sochanska AN, et al. Epidemiology, identification, treatment and return to play of musculoskeletal-based ice hockey injuries. British Journal of Sports Medicine. 2014;48(1):4-10.

Advanced Surface Technologies for Bone Fusion Webinar

Listen to Dr. Burkus talk about advanced surface technologies in ceramic bone graft substitutes and spinal implants that have demonstrated the ability to better support bone healing in spinal fusions, which can lead to improved outcomes for patients.

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  • Current state of ceramic bone graft substitutes and implants
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See this content on the NuVasive website

Dr. Kenneth Burkus is a board-certified orthopedic spine surgeon at the Hughston Clinic, Columbus, GA.
NuVasive, a global medical device company, partnered with Dr. Burkus to develop this educational content.
Dr. Burkus was compensated by NuVasive for his time.

Anterior Cruciate Ligament Reconstruction

The anterior cruciate ligament (ACL) tear is a common injury to the knee with approximately 400,000 reconstructions performed annually. Most people who experience the injury report feeling a pop after making a sudden move to change directions or pivoting during sports play. Soon after the sprain (tear) occurs you experience pain and swelling around the knee.

 

Knee anatomy

With its multiple structures and capsular attachments, the knee joint tends to be on of the most mobile joint in the body allowing for rotation, flexion (bending), and extension (straightening) during movement. The largest joint in the body, the knee is made up of the lower end of the femur (thighbone) and the upper end of the tibia, or shinbone (Fig. 1). The patella (kneecap) slides in a groove at the end of the femur. Furthermore, the knee is a diarthrodial joint, which is characterized by the presence of a layer of cartilage that lines the ends of the bony surfaces of the femur and tibia. Cartilage inside the joint helps to cushion and absorb shock providing stability to the knee, and tendons connect the muscles to the bones. Ligaments of the knee are tough, flexible, fibrous connective tissues at the end of the femur, tibia, and fibula that connect the bones, which also help stabilize and support the knee.

 

Knee ligaments

Four main ligaments help stabilize the knee; the medial (inner side) and lateral (outer side) collateral ligaments resist side-to-side motion, and the anterior (front) and posterior (back) cruciate ligaments resist forward and backward motion, respectively (Fig. 1). These 2 ligaments form a cross shape with their orientation in the center portion of the knee, which is why they are termed “cruciate” ligaments. The ACL provides most of the support that prevents the tibia from slipping forward against the femur. The ligaments work together with the medial and lateral menisci (crescent-shaped cartilage) and the leg muscles to stabilize the joint and allow the knee to generate and deliver the large quantities of power required for activities.

 

Ligament tear

During an injury to the knee, 1 or multiple ligaments may be disrupted or torn; however a tear of the ACL is one of the most common ligament injuries (Fig. 2). Partial tears are rare, so when an ACL injury does occur it is usually a complete tear. The patient often describes a feeling of a “pop” and there is usually immediate swelling of the knee. This is commonly associated with a noncontact pivoting injury during a sporting event. Once an injury has occurred, it is essential to get a thorough examination, most preferably at the time of injury or soon thereafter to determine which structures have been damaged.

With today’s technology, nearly all patients with suspected knee ligament injuries undergo magnetic resonance imaging (MRI, a scan that shows the bones, muscles, tendons, and ligaments) to fully evaluate all the soft tissue structures as well as bony anatomy to determine the extent of the injury. Once the physician has determined what structures are injured, treatment options to restore normal function can be discussed with the patient.

 

Nonsurgical treatment

Nonsurgical treatment can be an option for low-demand patients with decreased flexibility and those who have no feeling of instability about the knee. This treatment plan involves physical therapy, bracing, and lifestyle modifications. On the other hand, for young, active patients, or patients who continue to have episodes of instability where they complain that their knee “buckles” or “gives way” or they “do not trust their knee”, surgery is the best solution.

 

Weighing the pros and cons of surgery

Deciding to have surgery can be a difficult decision, especially since patients must not only weigh the risks, they must also consider the time it takes for recovery. As with any surgery, ACL reconstruction has risks and possible complications and the outcome is not guaranteed to be 100% successful. For patients who live an active lifestyle, ACL reconstruction is a good option, especially if they want an early return to sport. Additionally, the surgery helps prevent future damage to the knee cartilage and provides the best option to regain a normal functioning knee.

 

ACL reconstruction surgery

There have been many techniques to “repair” the ligament back to bone with sutures; unfortunately, repair of the anterior cruciate has had a high failure rate. There have also been attempts at making a synthetic ligament out of Gore-Tex, carbon fiber, and modified silk scaffolds. None of these techniques have performed well over time; therefore, the gold-standard for the treatment of an ACL tear in skeletally-mature (the bones are no longer growing) patients remains reconstruction. Especially in young active patients with persistent instability, it is recommended that they undergo reconstruction of the ACL.

Reconstruction involves using a tendon graft, which is a piece of healthy tendon that is transplanted surgically to replace the torn ACL. The tendon graft can come from the patient (autograft) or from an organ donor (allograft). Autografts are primarily used in younger more active patients, while allografts are reserved for older patients. The graft can come from many different tendon donor sites to include the hamstring tendons, the quadriceps tendon, or the patellar tendon; however, the decision is often determined by the surgeon’s preference and experience. Most ACL reconstructions are performed arthroscopically (a tiny camera and instruments inserted into the joint through small portals). The new ACL graft is secured into tunnels or sockets placed into the anatomic position on the tibia and the femur using a variety of techniques and devices, such as metal screws, bio-absorbable screws, suspensory fixation devices, and others with the goal to recreate a new ACL and restore stability to the knee.

 

After surgery

Postoperatively, patients are allowed to weight bear as tolerated on the reconstructed knee with the aid of a hinged type knee brace that provides stability while enabling early range of motion. Early physical therapy focuses on exercises that do not place excess stress on the graft. The goals during the first 4 to 6 weeks are to minimize pain and swelling, restore patellar mobility, restore quadriceps activation, and to normalize motion and gait pattern. During the 6 to 12 week postoperative phase, the emphasis is focused on developing strength, stability, and endurance with expected full clearance for return to sport at 6 months or beyond.

 

A good option for active people

ACL reconstruction using a tendon graft is a reliable and proven way to restore stability to the knee and return patients to their pre-injury activity level. If you have torn your ACL and are facing the decision on whether or not to undergone reconstruction, you should discuss your options with an orthopaedic surgeon who is experienced in the surgery. Depending on your activity goals, ACL reconstruction may be the best decision for your active lifestyle.

 

Author: Garland K. (Jake) Gudger, Jr., MD | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 31, Number 1, Winter 2019.

Managing the Polytrauma Patient

Every day, individuals are brought to emergency rooms or trauma centers with multiple injuries as a result of traumatic events such as car or motorcycle crashes or other high-energy impacts to the body, including falls from heights, crush injuries, or gunshots. A person involved in a traumatic event who has sustained multiple injuries is a polytrauma patient (Fig.). The term polytrauma comes from the ancient Greek words poly-, meaning many or multiple, and trauma, meaning a wound or an injury to living tissue caused by an external agent. The Centers for Disease Control (CDC) reports that 192,000 people under the age of 46 died from traumatic injuries in 2014. The CDC also states that, after heart disease and cancer, trauma is the leading cause of death for adults over the age of 45. However, current advances in treatment are helping to improve outcomes for polytrauma patients.

 

A multidisciplinary approach
Treatment of the polytrauma patient requires both a multidisciplinary approach and the proper timing of musculoskeletal care. Thus a coordinated effort by several highly specialized medical teams is usually required to manage and stabilize the polytrauma patient. The first responders take care of the initial resuscitation and transport of the patient by ambulance or helicopter to either the hospital or trauma center. There the patient is triaged and initially listed as being in 1 of 4 possible conditions: 1) physiologically stable; 2) unstable; 3) borderline; or 4) in extremis (extremely unstable). As traumatically sustained injuries often cause either internal bleeding or bleeding from an injured extremity, the amount of blood lost usually determines the patient’s condition. This blood loss is initially treated by administering fluids directly into the patient’s blood stream or through blood transfusions. The emergency medicine team then works to further stabilize the patient through lifesaving protocols and to evaluate the patient’s injuries by obtaining the proper imaging. Based on these images, the radiologist then aids in diagnosing these injuries, and an interventional radiologist can often treat ongoing bleeding through minimally invasive techniques.

Next, the orthopaedic trauma surgeon is responsible for stabilizing the patient’s musculoskeletal injuries based on his or her condition. As fractures can cause ongoing bleeding—for example, patients with pelvic or femur fractures can lose several liters of blood—temporarily splinting, and so stabilizing, a fracture can be lifesaving.
Afterward, depending on the patient’s clinical condition, treatment consists of 1 of 2 basic approaches for musculoskeletal stabilization: damage control orthopaedics (DCO) or early total care (ETC). Once the patient has been stabilized through 1 of these treatment protocols, intensive care unit (ICU) physicians and nurses assume the major responsibility for the patient’s care. The patient will remain in the ICU until his or her clinical condition improves enough to allow transfer to a regular hospital floor bed.

 

What is damage control orthopaedics (DCO)?
DCO is the performance of lifesaving interventions through rapid fracture stabilization to stop the cycle of ongoing musculoskeletal injury and bleeding. In patients with unstable pelvic fractures, the pelvis can be a source of ongoing bleeding. Thus pelvic binders or sheets are often applied around the patient’s pelvis to compress the area and stop the bleeding. Additionally, external fixators—pins placed into the bone that are connected to bars and clamps applied outside the body—are frequently positioned to stabilize fractures and soft tissue injuries of not only the pelvic area, but also the extremities. These interventions are able to stabilize the patient quickly without the added insult to the body that more invasive surgery would entail.

 

What is early total care (ETC)?
ETC is the performance of definitive fracture stabilization at the time of the initial surgery. One advantage of this approach is that it can enable the patient to get back on his or her feet sooner. It can also help prevent other health issues, such as pneumonia, ulcers from lying in bed, blood vessel abnormalities (such as blood clots), gastrointestinal problems, and even mood disorders, from occurring due to the more rapid mobilization of the patient after surgery. However, as surgery involving definitive fracture stabilization often takes more time and is more invasive, performing this type of treatment on an otherwise unstable patient can add insult to injury. ETC should therefore be performed only on those patients who are already in stable condition.

 

Better management, better outcomes
Two major factors affecting early survival of the polytrauma patient are the initial status of the patient (determined largely by the amount of blood loss sustained) and the time to transfer the patient to a trauma center. Brain injury, which is often the result of blunt trauma, can cause early death in the polytrauma patient, while sepsis (an inflammatory response caused by infection and involving the entire body) typically causes death later on. Fortunately, advances in diagnosis and treatment of traumatic musculoskeletal injuries—including prehospital, interventional, surgical, and intensive care—have led to increased survival rates for polytrauma patients.

 

Author: Aaron D. Schrayer, MD | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 28, Number 3, Summer 2016.