Orthopedists too Conservative With Load Bearing?
You put a lot of work into that surgery. Why not play it safe and restrict load bearing? Because, says Erik Kubiak, M.D. and collaborators, the patient may likely undergo unnecessary functional decline and prolonged periods of lost productivity…and because medicine should be based on science. Dr. Kubiak, an associate professor at the University of Utah Medical Center, tells OTW, “My colleagues and I have just published a review article in the Journal of the American Academy of Orthopaedic Surgeons indicating that weight-bearing protocols are often applied arbitrarily based on little objective data. Certain studies suggest that patients with normal protective sensation—those who autoregulate—can safely bear weight sooner than most protocols permit. Then there are the randomized, controlled trials of ankle fractures that have shown no difference in outcomes between immediate and delayed (≥6 weeks) weight bearing. Yet patients with periarticular fractures may not fare as well with early weight bearing.”
“My colleagues and I began considering this issue of autoregulation. Pediatric patients do what they want; older people do what they want. We were struck by the question, ‘What is it about those patients in the middle. What makes humans irrational between 20 and 50 years old?’ When you begin discussing restricting weight bearing you move into the realm of opinion; for example, you might hear, ‘They should wait because I don’t want them to hurt themselves or worse yet develop wound or fracture healing complications.’ We realized that there was no concrete evidence to support one way or another. The best evidence we have says that people will autoregulate based on pain—if they have a working neural pain protective mechanism/pain response. What we see in practice is that most patients are being overprotected.”
“I just had cervical spine fusion three weeks ago and my surgeon instructed me not to do any exercise of any kind. But there is nothing in the literature to support his directive! I’m fortunate to have a secure job, but for many people this kind of instruction can result in a prolonged periods of non productivity, anxiety, and depression.”
“We have obtained a grant from the Department of Defense to complete the development of a blinded activity monitoring system to better define the optimal healing parameters for lower extremity fractures. The ultimate aim would be to construct a patient based activity monitoring system which would facilitate an optimal rehabilitation program based on objective data with real time feedback to the patient and the treating physician.”
Popping, Clicking Knees May Be Fine
Shaking up traditional thought, researchers from Boston have found that those clicking, popping, and cracking sounds in the knee are not necessarily signs of a meniscal tear. Dr. Jeffrey Katz, a rheumatologist at Boston’s Brigham & Women’s Hospital and professor of medicine at Harvard University, tells OTW, “We asked whether the assessments of experienced physicians as to whether the patient did or did not have a meniscal tear agreed with typical signs and symptoms like clicking and locking and giving way. We found poor agreement between these signs and symptoms and the experts’ diagnosis of symptomatic meniscal tear. Our study, which involved individuals who were all 40 or older, found that many of the mechanical symptoms people experience (like the popping sensation) are actually their own perceptions of OA [osteoarthritis] symptoms. We’re imposing the paradigm developed in younger people onto those who are middle aged.”
“Patients who had symptoms that were more typical of chronic OA tended NOT to have symptomatic meniscal tears. Also, people with patellofemoral tenderness or anterior knee pain tended not to have symptomatic mensical tears. We concluded that while 1/3 of the middle aged and older adults have meniscal tears on their MRIs, we don’t know how to identify which of these tears are symptomatic. The symptoms we’re accustomed to linking with meniscal tear may not be useful. At this point we need to reevaluate our rules of thumb about diagnosis and prognosis of meniscal tear. We can’t rely on what we learned about how a meniscal tears acts in younger people to inform the diagnosis of symptomatic tear in older persons.”
Revision Osteochondral Allograft: Patient Characteristics Determine Success
Do revision osteochondral allograft transplantations work? William Bugbee, M.D., an orthopedic surgeon with Scripps Clinic in La Jolla, California, wanted to find out. “We did a case series of 33 patients (33 knees) and found that indeed allografts are a versatile option for biologic joint restoration. Revision osteochondral allograft transplantation of the knee did result in acceptable outcomes, but they did not match those of primary allograft transplantation procedures.”
“The key finding is that it is really the patient characteristics that predict long-term outcome. If the person is older or has a fair amount of arthritis the results are inferior. This is predictable and makes sense. We would still try an allograft in a patient that is too young or not interested in artificial joint replacement, but with the knowledge that the results are not predictable. In younger patients that have a failed allograft we are confident about doing it again.”
“As for future research, on the clinical side we are continuing to look at all aspects of outcome: patient characteristics, diagnosis, technique and the biology of how the grafts behave in vivo.”
$1 Million to HSS, Others for OA Research
Hospital for Special Surgery (HSS) in New York, the University of California, San Francisco, and Mayo Clinic in Rochester, Minnesota will share $1 million awarded by the Arthritis Foundation to validate the use of new MRI techniques and newly identified biomarkers in identifying early stages of osteoarthritis. Scott Rodeo, M.D. is an orthopedic surgeon and co-chief of the sports medicine and shoulder service at HSS and co-principal investigator of the tripartite grant. He said in a November 12, 2013 news release, “Using X-rays to measure joint space narrowing is the gold standard for assessing the presence and progression of osteoarthritis, but X-rays are next to worthless for detecting the early changes of arthritis. This study will help us understand the early factors that lead to the degenerative changes in ACL [anterior cruciate ligament] injured knees.”
Asked about the early factors that lead to these changes, Dr. Rodeo told OTW, “The early changes are likely due to a combination of both biomechanical and biological changes in the injured joint. I believe that biomechanical and kinematic alterations may be the primary initiating factor. These changes likely lead to abnormal and excessive loading of different areas of articular cartilage. The presence of inflammatory mediators and other metabolic alterations also likely contribute to the degenerative process, especially in the setting of the altered biomechanics.”
“One year from now we hope to have begun to identify imaging biomarkers (using quantitative MRI) that provide the ability for early detection of degenerative articular cartilage changes.”
James Andrews, M.D. to Receive Gerald Ford Award
The National Collegiate Athletic Association (NCAA) is reporting that famed sports medicine surgeon James Andrews, M.D. will be the 2014 recipient of the NCAA President’s Gerald R. Ford (“Andrews named recipient of Ford Award, ” December 12, 2013, Greg Johnson). Dr. Andrews, a former president of the American Orthopedic Society of Sports Medicine, is receiving this work as recognition of his contributions to student-athlete well-being and his work regarding injury prevention. Dr. Andrews is known internationally for his work with elite athletes and for his extraordinary efforts to raise awareness regarding injury prevention. He sits on the Medical and Safety Advisory Committee for USA Baseball and on the Board of Little League Baseball, and has made recommendations that have led to the establishment of pitch counts in youth baseball. Dr. Andrews also developed the widely-recognized STOP program, which stands for Stop Trauma Overuse Prevention in youth sports.
Dr. Andrews is one of the founding members of Andrews Sports Medicine and Orthopaedic Center in Birmingham, Alabama. He is also a founder of the American Sports Medicine Institute (ASMI) a non-profit institute dedicated to injury prevention, education and research in orthopedics and sports medicine. Doctor Andrews continues to serve as Chairman and Medical Director of ASMI. He has mentored more than 275 orthopedic/sports medicine fellows and more than 55 primary care sports medicine fellows.
Dr. Andrews is senior consultant for the Washington Redskins Professional Football team; medical director for the Tampa Bay Rays Professional Baseball Team; and team physician for the Birmingham Barons Double A Professional Baseball Team, an affiliate of the Chicago White Sox. Doctor Andrews is the medical director of the Ladies Professional Golf Association.
Dr. Andrews has been a member of the Sports Medicine Committee of the United States Olympic Committee having served during two previous quadrennia. He has also served on the NCAA Competitive Safeguards in Medical Aspects of Sports Committee.
