The increasing need for nonoperative treatment of patients with osteoarthritis.

Osteoarthritis affects more patients than almost any other musculoskeletal disorder. The number of patients suffering joint pain and stiffness as a result of this disease will increase rapidly in the next decade. Although operative treatments of patients with osteoarthritis will continue to improve and the number of operative procedures will increase slightly in the next decade, only a small fraction of the patients with osteoarthritis will require operative procedures. The most pressing healthcare need for the majority of patients with osteoarthritis is nonoperative care that helps relieve symptoms and improve function, and in some instances slows progression. In rare instances, the symptoms of osteoarthritis improve spontaneously, but most patients need nonoperative care for decades. Orthopaedists need to improve their ability to provide nonoperative care for patients with osteoarthritis. They should be skilled in the early diagnosis of osteoarthritis and in the use of current common nonoperative treatments including patient education, activity modification, shoe modifications, braces, oral analgesics, oral nonsteroidal antiinflammatory medications, oral dietary supplements, and intraarticular injections. Furthermore, orthopaedists should be prepared to incorporate new nonoperative treatments for patients with osteoarthritis into their practice.

Complications of metallic suture anchors in shoulder surgery: A report of 8 cases.

PURPOSE: Metallic suture anchors are widely used in open and arthroscopic operations about the shoulder. We report the cases of 8 patients who were referred to our institution with complications following shoulder surgery in which metallic suture anchors were used. TYPE OF STUDY: Retrospective case series. METHODS: There were 7 male patients and 1 female patient with an average age of 36 years (range, 18 to 76 years). The initial operation was open anterior reconstruction for anterior instability of the glenohumeral joint in 5 patients, open rotator cuff tear repair in 2 patients, and an open posterior capsular reconstruction for posterior instability in 1 patient. All patients were referred for evaluation after a failed index reconstructive procedure. RESULTS: On average, 5.5 suture anchors (range, 3 to 8) per shoulder were used. Of 4 patients undergoing reconstruction with glenoid anchors only, 3 patients had an extraosseously positioned device. In this subset of glenoid-sided reconstructions, when more than 3 anchors were used, at least 1 anchor was inserted in an extraosseous position. In 2 of 3 patients with isolated humeral anchors, there was evidence of migration over time (1 intra-articular, 2 bursal). Three patients (38%) developed severe articular damage that was directly caused by a loose or intra-articular metal suture anchor. One patient developed a wound infection after reconstructive surgery. In all 8 patients, the index procedure failed and required subsequent surgery. CONCLUSIONS: The use of metallic suture anchors about the shoulder is commonplace and useful, but, as with other hardware used about the shoulder, there are significant risks if the anchors are improperly placed or if the index procedure fails.

A comparison of operative times in arthroscopic ACL reconstruction between orthopaedic faculty and residents: the financial impact of orthopaedic surgical training in the operating room.

There is no published data regarding the financial impact of training orthopaedic residents in the operating room. No comparisons between orthopaedic faculty and residents in regard to operative time and costs are known. One hundred eleven cases of anterior cruciate ligament reconstruction with or without partial meniscectomy were evaluated from 1996 to 1997. Fifty-three cases met the selection criteria of times, documentation and identification of the surgeon. Twenty-one cases were performed by the orthopaedic attending (RCS) while 32 cases were performed by the senior orthopaedic resident. All procedures had the same faculty member present in the operating room either as the primary surgeon or as an assistant providing supervision and instruction as needed. In a two year period, comparisons were made between the attending and residents for the total anesthesia time and actual operative case time. Attending case time and anesthesia times averaged 94.62 minutes (range 60-125 min) and 128.1 minutes (range 84-185 min) respectively. Resident case and anesthesia times averaged 137.09 minutes (range 95-210 min) and 190.48 minutes (range 145-255 min) respectively. The anesthesia time was significantly less for the attending (p<.0001) as was the case time (p<.0001). The true costs of training orthopaedic surgery residents in the operating room is not known. The operative time and subsequent cost difference between experienced faculty and orthopaedic residents in certain arthroscopic procedures is not inconsequential. On average, the difference is equivalent to $228.73 per case for anesthesia costs. Based on increased operative times, operating room costs, on average, were increased by $661.85. The significant differences demonstrated between residents and faculty suggest the need to develop strategies and technical training facilities in order to improve orthopaedic residents' surgical skills and efficiency outside of the cost-central operating room.

Argument against use of food additives for osteoarthritis of the hip.

Food additives and other forms of alternative medicines have been embraced by the general public. Some of these compounds including glucosamine and chondroitin sulfate have shown efficacy in relieving pain associated with osteoarthritis. However, evidence is limited concerning the chondroprotective ability of these agents. More controlled studies and basic research is necessary to evaluate these claims especially because these compounds are not under regulatory control.

Cruciate injury patterns in knee hyperextension: a cadaveric model.

We created an experimental model to evaluate the effects of strain rate on the mechanism of combined cruciate ligament injuries in knee hyperextension. Using straight knee hyperextension to rupture the anterior and posterior cruciates, two strain rates (approximately 100% per second and 5400% per second) were applied to reproduce two clinical injury patterns of the knee: low energy (sporting) and high energy (pedestrian-motor vehicle accident). Ten pairs of fresh-frozen cadaveric knees were injured to 45 degrees of hyperextension. Strain rate sensitivity of the posterior cruciate ligament was shown in this model, with midsubstance tears occuring in specimens tested at a low rate and avulsion "stripping" injuries from the femoral side occuring at a high rate. A variable pattern of anterior cruciate ligament tears at both high and low rates suggests that the specific injury mechanism may also involve other factors including notch morphology. We present a simplified mathematic model used to estimate posterior cruciate ligament strain during knee hyperextension.

Biomechanical topography of human articular cartilage in the first metatarsophalangeal joint.

The objective of this study was to provide a map of cartilage biomechanical properties, thickness, and histomorphometric characteristics in the human, cadaveric first metatarsophangeal joint, to determine if normal articular cartilage was predisposed topographically to biomechanical mismatches in articulating surfaces. Cartilage intrinsic material properties and thickness were obtained from seven pairs of human, freshly frozen, cadaveric, metatarsophalangeal joints using an automated creep indentation apparatus under conditions of biphasic creep. Eight sites were tested: four on the metatarsal head, two on the proximal phalanx base, and one on each sesamoid bone to obtain the aggregate modulus, Poisson's ratio, permeability, shear modulus, and thickness. Cartilage in the lateral phalanx site of the left metatarsal head had the largest aggregate modulus (1.34 MPa), whereas the softest tissue was found in the right medial sesamoid (0.63 MPa). The medial phalanx region of the right joint was the most permeable (4.56 x 10(-15) meter4/Newton-second), whereas the medial sesamoid articulation of the metatarsal head of the left joint was the least permeable (1.26 x 10(-15) meter4/Newton-second). Material properties and thickness are indicative of the tissue's functional environment. The lack of mismatches in cartilage biomechanical properties of the articulating surfaces found in this study may be supportive of clinical observations that early degenerative changes, in the absence of traumatic events, do not occur at the selected test sites in the human first metatarsophalangeal joint.

Management of shoulder dysfunction with an alternative model of orthopaedic physical therapy intervention: a case report.

One common approach to patient care in dealing with many musculoskeletal dysfunctions involves two to three patient visits to physical therapy per week over a period of weeks. Some patients may benefit from an alternative, graduated treatment model emphasizing a minimal number of office visits and focusing on intensive patient education, home program therapeutic exercise, and specific manual interventions. Patient education focuses on home program compliance and empowerment of the patient by adjusting office visits as needed based on patient progress rather than multiple patient contacts in the first weeks. This emphasis may improve long-term patient compliance by preventing the development of an external locus of control in which the patient is dependent upon the therapist for management of his/her condition. This case study is an example of the use of this alternative treatment model for the resolution of impingement syndrome and adhesive capsulitis in a 53-year-old female. A comprehensive program of patient education and home exercise was initiated during the first visit. Joint mobilization and active exercise were performed at each subsequent visit. The patient was seen a total of six visits over a period of approximately 10 1/2 weeks, followed up via telephone at 1 month after the last treatment and reexamined after 1 year. The objective exam revealed no abnormalities after the last visit or after 1 year. The patient subjectively reported compliance with the home program for 6 months after the last visit. This model of patient care was successful for the patient described in this case study. The treatment approach may have contributed to the development of an internal locus of control by allowing the patient to be as actively involved as possible in the treatment of her condition. In addition, this approach is timely when one considers current reimbursement systems. Though successful with this patient, this graduated treatment model is not intended to be applicable to every patient with this diagnosis.

Human articular cartilage biomechanics of the second metatarsal intermediate cuneiform joint.

Intrinsic material properties and histomorphometry of freshly frozen, human cadaveric cartilage from the second metatarsal intermediate cuneiform (SMIC) articulation were obtained to provide biomechanical mapping of the surfaces. The biphasic creep indentation methodology and an automated creep indentation apparatus were used to measure aggregate modulus, Poisson's ratio, permeability, shear modulus, and thickness. Biomechanical experiments were performed on four sites of the SMIC joint in 14 specimens (seven pairs): two sites in the second metatarsal base and two sites in the intermediate cuneiform head. Results of the study indicate that no significant variations exist in the biomechanical comparisons between specific articulations, gross articulations, and left and right joints. For example, cartilage from the second metatarsal base and intermediate cuneiform head had an aggregate modulus of 0.99 MPa and 1.05 MPa, respectively. The Poisson's ratio and permeability of all test sites grouped together were found to be 0.08 and 3.05 x 10(-15) m4/N.s, respectively. Cartilage thickness was measured at 0.61 mm. This biomechanical study suggests that similarities in cartilage properties may be beneficial in preventing the human SMIC articulation from developing early degenerative changes. Histological evaluation demonstrated that SMIC cartilage exhibits structural characteristics (such as the absence of chondrocyte columnar arrangement in the deep zone) which may be typical of cartilage that does not experience habitually high compressive stresses. This knowledge could aid surgeons in generating a deeper perspective of the relationship between clinical pathologies of articular cartilage and intrinsic biomechanical etiologies of degenerative joint diseases.

Morphology of the axillary nerve in an anteroinferior shoulder arthroscopy portal.

An anteroinferior portal can be safely used in arthroscopic shoulder surgery but requires an in-depth knowledge of axillary nerve anatomy. The purpose of this report is to present the qualitative and spatial anatomy of the axillary nerve and to describe patterns of arborization that may affect safe anteroinferior arthroscopic portal placement. Measurements were taken in 42 embalmed cadaveric shoulders (20 male, 22 female). The distance from the acromioclavicular (AC) joint to the axillary nerve averaged 7.90 cm (range, 7.2 to 9.1 cm) in males and 6.37 cm (range, 5.2 to 8.1 cm) in females. We describe the axillary nerve index (distance of nerve from the AC joint/length of deltoid from AC joint) which can be used to predict the location of the axillary nerve along the anterior clavicular line (ACL). The axillary nerve index averaged 0.48 (range, 0.42 to 0.57) in males and 0.41 (range, 0.31 to 0.57) in females. Four types of morphology were noted in the axillary nerve: (1) main trunk with superior and inferior branches, (2) main trunk with superior branches, (3) main trunk with inferior branches, and (4) main trunk only. Our work supports the traditional operable safe zone for the axillary nerve.

Porous-coated titanium implant impregnated with a biodegradable protein delivery system.

Tissue ingrowth into porous-coated orthopedic and dental implants is commonly used as a means to achieve long-term fixation of these prostheses. However, the degree of tissue ingrowth is often inadequate and inconsistent. If the pores of these implants are impregnated with a controlled drug release system delivering relevant growth factors, then it might be possible to stimulate more tissue ingrowth. The present study introduces such a system based on biodegradable polymers and investigates its protein release profile and polymer degradation characteristics. Porous coated titanium implants were impregnated with a mixture of a 50%-50% polylactic acid-polyglycolic acid copolymer and a model protein, soybean trypsin inhibitor. Control implants contained only the polymer and no protein. The implants were subjected to hydrolytic degradation in phosphate buffered saline at 37 degrees C for periods of 3, 6, and 11 weeks. The protein release and the mass and molecular weight of the polymer were monitored. The results indicate that the protein is released in three distinct phases and the polymer loses almost all its mass and molecular weight by 11 weeks. There was a significant difference in the polymer degradation characteristics between the control and test implants, which might be the result of some complex polymer-protein interactions.

Femoral-sided fracture-dislocation of the knee.

OBJECTIVE: To document a previously undescribed fracture-dislocation of the knee that involves a femoral condyle and associated ligaments yet spares the tibial joint surface. DESIGN: Retrospective. SETTING: University. PATIENTS: Four cases of fracture-dislocation of the knee that involve ligamentous injury and fracture of the femoral condyle(s). RESULTS: At a minimum two-year follow-up (average 28.8 months, range 26 to 37 months), overall functional outcome is only fair to good in this injury pattern. The Lysholm knee rating averaged 60 (range 39 to 74) and KT-1000 I-N testing averaged three millimeters at thirty pounds. CONCLUSION: Despite treatment of this fracture-dislocation with internal fixation of the femoral condyle(s) and repair of the ligament(s), functional deficits occur in this severe knee injury patterns.

A prospective outcome study of rehabilitation programs and anterior cruciate ligament reconstruction.

We evaluated the outcome of and compared two rehabilitation programs (clinic-based versus home) after a mid-third patellar autograft reconstruction of the anterior cruciate ligament. Thirty-seven patients (28 male, 9 female; average age, 24.1 years) completed the study. Fifteen of these patients received clinic-based rehabilitation (three visits per week for 6 weeks prescribed), and 22 patients received home-based physical therapy (number of visits determined by patient response). Knee ROM, Lysholm, Visual Analogy Scale, (VAS) pain rating, hop test, KT-1000, and Sickness Impact Profile (SIP) were evaluated preoperatively and postoperatively. All patients reported good satisfaction with the function of their knee at average follow-up of 21.6 months (range, 12 to 48). Patients managed by home rehabilitation averaged 2.85 visits as compared with 14.2 for clinic-centered patient (P < .05). There were no differences in functional or subjective outcomes in the different postoperative rehabilitation regimens, with both groups reporting high satisfaction and improved quality of life. Cost savings in the home rehabilitation group were significant.

Clinical and anatomic considerations in the use of a new anterior inferior subaxillary nerve arthroscopy portal.

The axillary nerve has been an obstacle to safety creating bone tunnels for arthroscopic rotator cuff repair. Anatomic dissections of 42 cadaver shoulders have defined anatomic relationships that have allowed the authors to develop a safe arthroscopy portal distal to the axillary nerve. The senior author (SSB) has used this portal without complications in achieving arthroscopic transosseous rotator cuff repair. This portal allows the proper angle of approach to locate the distal hole of the tunnel in strong cortical bone.

Fractures of the hand.

In managing any fractures of the hand, the basic principles of fracture management are the same whether treatment is closed or open. They are 1. Accurate reduction and stabilization of the fracture 2. Elevation and edema control 3. Mobilization of the unaffected joints 4. Early range of motion of the injured digit or digits when healing processes permit. Special situations and injuries require amendments to the basic principles. Open fractures require early and thorough wound debridement. Early fixation and serial wound debridement to assure a proper environment for bone or skin grafting are essential in caring for these severe injuries (Figs. 13-15). Numerous fixation techniques ranging from simple plaster splints, K-wires, external fixators, and small plates and screws are available for fracture care. Fractures of the hand are very common injuries that demand early recognition and treatment. The majority of fractures can be treated with closed methods. Recognition of those injuries that require operative treatment and prompt attention to detail and surgical technique will prevent many of the complications associated with these frequently encountered problems.