Clinical application of shock wave therapy (SWT) in musculoskeletal disorders.

Currently the application of shock wave therapy (SWT) in musculoskeletal disorders has been primarily used in the treatment of tendinopathies (proximal plantar fasciopathy, lateral elbow tendinopathy, calcific tendinopathy of the shoulder, and patellar tendinopathy, etc.) and bone defects (delayed- and non-union of bone fractures, avascular necrosis of femoral head, etc.). Although the mechanism of their therapeutic effects are still unknown, the majority of published papers have shown positive and beneficial effects of using SWT as a treatment for musculoskeletal disorders, with a success rate ranging from 65% to 91%, while the complications are low or negligible. The purpose of this paper is to inform the reader about the published data on the clinical application of SWT in the treatment of musculoskeletal disorders. In this paper, with the help of a literature review, indications and success rates for SWT in the treatment of musculoskeletal disorders are outlined, while adequate SWT parameters (e.g., rate of impulses, energy flux density, etc.) are defined according to the present state of knowledge.

[Extracorporeal shockwave therapy in the treatment of chronic insertional Achilles tendinopathy]. / Extrakorporale Stosswellentherapie zur Behandlung der Achillessehnentendinopathie.

PURPOSE: The purpose of this study was to determine the efficacy of extracorporeal shock wave therapy (ESWT) for the treatment of adults with chronic insertional Achilles tendinopathy. METHODS: 68 patients with chronic insertional Achilles tendinopathy were enrolled in this study. A total of 35 patients were treated with a single dose of ESWT (3000 shocks of 0.20 mJ/mm(2), ESWT group), while 33 patients were treated with traditional non-operative measures (control group). RESULTS: At 3 months post treatment, the mean VAS for the control and ESWT groups were 2.9 and 7.2 respectively. Using the Roles and Maudsley scale, 39% of the control patients and 51% of the ESWT patients were assigned an excellent or good result. CONCLUSIONS: ESWT as applied is a safe and effective treatment for chronic insertional Achilles tendinopathy.

Isometry measurements in the knee with the anterior cruciate ligament intact, sectioned, and reconstructed.

When assessing isometry during anterior cruciate ligament surgery, it is assumed that points determined to be isometric remain so after reconstruction. We sought to evaluate if isometric measurements vary with the status of the anterior cruciate ligament. A computerized electronic isometer was used to measure the magnitude and pattern of change in separation distance between a constant point in the tibial insertion of the anterior cruciate ligament and five positions within the femoral insertion with the anterior cruciate ligament intact, sectioned, and reconstructed. For the center position, the magnitude and pattern of the change in separation distance was physiologically isometric in all conditions (maximal length change, 3.0 mm). For the posterior position, the isometry pattern remained physiologic in each condition, and the magnitude of the separation distance was nearly isometric in all conditions (maximal length change, 3.7 mm). The superior and inferior positions had similar isometric measurements in the intact and sectioned conditions but significantly different measurements after anterior cruciate ligament reconstruction. Intraoperative assessment of isometry at positions in the center or posterior portion of the anterior cruciate ligament's femoral insertion provides useful information that is not altered by reconstruction. For superior and inferior positions, however, points found to be isometric in the anterior cruciate ligament-deficient knee did not remain isometric after reconstruction.

The efficacy and safety of the hematoma block for fracture reduction in closed, isolated fractures.

Fracture manipulation in the emergency department often requires some method of anesthesia. This study evaluates the efficacy and safety of the hematoma block in patients with closed, isolated fractures requiring manipulative reduction. Sixty-one patients treated with a hematoma block (HB group) prior to fracture manipulation were compared with 53 patients treated with either intravenous sedation or "conscious sedation" (NHB group). Using a pain analog scale, patients rated their pain from 1 (no pain) to 10 (severe pain) both prior to and during fracture manipulation. A pain differential score was calculated for each group. Results demonstrated pain differential scores of 2.7 and 0.8 for the HB and NHB groups, respectively. There were no complications associated with any of the procedures. Based on these results, we conclude that the hematoma block is an effective and safe method of providing anesthesia for fracture reduction in select patients.

Tuberculous arthritis of the knee presenting as a meniscal tear.

Nonspinal skeletal tuberculosis is a rare, indolent disease that is often difficult to diagnose. The incidence in the United States has recently increased. Pain and swelling are common symptoms. Radiographs may reveal normal findings, or in more advanced cases, demonstrate osteopenia, marginal erosions, and eventually, joint space narrowing and destruction. Treatment depends on the extent of the disease. Prolonged therapy with antitubercular agents is the mainstay of treatment. Synovectomy, osseous debridement, and arthrodesis also have a role in the treatment of this infection.

Heterotopic ossification following primary total knee arthroplasty.

Ninety-eight consecutive primary total knee arthroplasties (TKAs) in 70 patients were retrospectively evaluated for heterotopic ossification (HO). A radiographic classification was devised based on the extent and location of the ectopic bone. Twenty-five knees (26%) in 19 patients developed HO. Eight of 11 patients (73%) with preexisting heterotopic bone at other sites developed HO in the index knee. Multivariate analysis demonstrated that advanced HO was associated with restricted knee motion. Eight knees with advanced HO had a mean 14 degrees decrease in postoperative, as compared with preoperative, knee flexion (P < .05). For all patients with HO, mean lumbar spine bone mineral density (BMD) was significantly elevated compared with a matched control group not developing HO (P < .05). Heterotopic ossification following primary TKA correlates with a limitation of postoperative knee flexion and is predicted by increased lumbar BMD. Preoperative measurement of spinal BMD may identify those patients at risk for HO and allow for the institution of preoperative prophylaxis and modification of postoperative rehabilitation to optimize functional outcome following TKA.

Hematoma block for ankle fractures: a safe and efficacious technique for manipulations.

The purpose of this study was to examine the safety and efficacy of the hematoma block technique for closed ankle fracture manipulation. Twenty-three patients received a hematoma block with or without supplemental analgesia and/or sedation for the manipulative reduction of an ankle fracture, and 37 patients received parenteral agents alone. At an average of 12 months post-reduction, patients were administered a questionnaire concerning their level of discomfort surrounding the manipulation of their acute injury. Their experienced level of pain was recorded on a pain analog scale at the time of injury, at the time of reduction, and at the time of the questionnaire. Other queries were made regarding their recall of other aspects of their acute care treatment. The hematoma block group noted their pain differential to be 3.4 less during reduction compared with the time of injury. In the 17% subgroup of hematoma block patients who received no supplemental parenteral analgesia, the pain differential was noted to be 4.5 less during reduction. This was in contrast to the non-hematoma block group, which rated their pain differential to be 0.6 between injury and reduction. In addition, the hematoma block procedure resulted in no associated complications. The results of this study led us to conclude that the hematoma block with or without supplemental analgesia for the manipulation of ankle fractures was safe and effective and is a useful technique. This is particularly true in those patients in whom an adequate dosage of parenteral medication is contraindicated or unsafe.

Atrophy of the proximal part of the femur after total hip arthroplasty without cement. A quantitative comparison of cobalt-chromium and titanium femoral stems with use of dual x-ray absorptiometry.

The purpose of this study was to compare the density of periprosthetic bone about titanium and cobalt-chromium stems that had been inserted without cement. The analysis was done, three to four years after a total hip arthroplasty, in a retrospectively matched cohort of thirty patients. Fifteen patients had a stem that was collarless, proximally coated, and made of titanium; the other fifteen had a stem of similar design that was made of cobalt-chromium. The criteria for selection in the study included an excellent clinical and radiographic result and separately calculated modified Harris and Mayo hip scores of more than 94 points. All stems had radiographic evidence of osseous ingrowth. A comparison of the bone-mineral density about the two different types of stem with dual-energy x-ray absorptiometry revealed a significant difference only along the calcar of the femur. There was no significant difference about the remaining, preponderant portion of the proximal part of the femur. Our data suggest that the difference in the modulus of elasticity between the two types of stem had little effect on the loss of bone-mineral density in most of the proximal part of the femur after arthroplasty without cement.

An injection technique to create a bloodless field in arthroscopically assisted anterior cruciate ligament reconstruction.

We did a retrospective study of 67 patients who had arthroscopically assisted anterior cruciate ligament reconstruction using the middle one-third of the patellar tendon to evaluate a technique for creating a bloodless field using a local anesthetic with epinephrine injection (the injection technique). For 37 patients, the bloodless field was created using the injection technique. In 30 others, hemostasis was achieved in the usual fashion with the pneumatic tourniquet. All patients underwent general anesthesia. Mean operative time and length of hospital stay was similar for each group. Mean postoperative pain medication consumption was significantly decreased for patients treated with the injection technique. No clinically recognizable complications could be attributed to either technique. We conclude that subcutaneous and intraarticular injection of local anesthesia with epinephrine is a satisfactory method of establishing a bloodless field in arthroscopically assisted anterior cruciate ligament reconstruction operations.