Volume 1 | Issue 1
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Jopa Journal of Orthopedics for Physician Assistants Review Articles Lumbar Disc Herniation Factors Influencing Antibiotic Choice for Acute Osteomyelitis Preoperative Decolonization of MSSA/MRSA Nasal Carriage and the Effect on Orthopedic Postoperative Surgical Site Infections Nonoperative Treatment of Knee Osteoarthritis Sideline Diagnosis and Management of Sports-Related Concussions
Case Studies Osteoid Osteoma
Procedures in Orthopedics Fluoroscopic Hip Injections
Professional Issues and Experiences Combat Orthopedics PA Owned and Operated
Compliments of A Journal Created for Physician Assistants in Orthopedics
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Journal of Orthopedics for Physician Assistants
Journal Mission
Contents
The Journal of Orthopedics for Physician Assistants (JOPA) is an academic resource created to deliver ongoing orthopedic education for physician assistants. The journal is a unique forum to share our knowledge and experiences with colleagues in the profession. JOPA strives to publish timely and practical articles covering all subspecialties. Each article is peer reviewed to ensure accuracy, clinical relevance, and readability.
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Dagan Cloutier, PA-C, Editor in Chief BioScience Writers LLC (www.biosciencewriters.com), Content Editor Ryan Ouellette, Webmaster, thejopa.org Spectrum Marketing, Journal Design
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Message From the Editor Osteoid Osteoma Case Study One Case Study Two and Discussion
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Combat Orthopedics My Experience During Operation Enduring Freedom
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Image Quiz Hip Radiograph Interpretation
Procedures in Orthopedics Fluoroscopic Hip Injections
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Lumbar Disc Herniation Normal/ Abnormal Image Review Rotator Cuff Tears
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Writing for JOPA Information for Authors
Physician Assistant Review Board Brian Barry Portsmouth, NH Ryan Brainard Savannah, GA Afton Branton Geneva, NY Mark Carbo Alexandria, LA Ray Carlson San Diego, CA Jeff Chambers Athens, Georgia Larry Collins Tampa, FL Charles Dowell Vancouver, WA Caitlin Eagen Boston, MA Erich Fogg York, ME Bruce Gallio Reno, NV
Jennifer Hart Charlottesville, VA Jennifer Hartman Peoria, AZ Michael Harvey Fishers, IN Sean Hazzard Boston, MA Tim Holstrom Pullman, WA Mike Houle Hartford, CT Angela Grochowski Horsham, PA Alan Johnston Nashua, NH Stuart Jones Brentwood, TN Stanley J. Kotara Lubbock, TX Kathleen Martinelli Durham, NC
Patrick McCarthy Manchester, NH Terry Mize Atlanta, Georgia Randall Pape USAF Academy, CO Keith Paul Greensboro, NC Robert B. Rogan Johnson City, TN Bradford Salzmann Ware, MA Steve Steiner Manchester, NH Timothy Thompson Naples, FL Mary Vacala Savannah, GA Marcos Vargas Flushing, MI Scott Walton Caribou, ME
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Test Your Knowledge Quiz Infectious Disease Consult Factors Influencing Antibiotic Choice for Acute Osteomyelitis
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Preoperative Decolonization of MSSA/MRSA Nasal Carriage and the Effect on Orthopedic Postoperative Surgical Site Infections PA Owned and Operated Nonoperative Treatment of Knee Osteoarthritis Physical Therapy Corner The Graston Technique
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Sideline Diagnosis and Management of Sports-Related Concussions
This issue is presented to you by: Disclaimer: Statements and opinions expressed in articles are those of the authors and do not necessarily reflect those of the publisher. The publisher disclaims any responsibility or liability for any material published herein. Acceptance of advertising does not imply the publisher guarantees, warrants, or endorses any product or service.
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Message from the Editor This is an exciting time to be part of a growing profession as a physician assistant. PAs continue to emerge as a solution for high-quality, affordable care. As our profession grows, further emphasis will be placed on specialty recognition. The NCCPA recognizes orthopedics as one of five specialties deserving of a certificate of added qualifications program. In the future, our profession should consider developing a specialty-focused PANRE exam, particularly since many of us practice in the same specialty for our entire career. As PAs in orthopedics, we can further distinguish our specialty by creating a publication that promotes an orthopedicfocused education. Publications for physician specialties have existed for many years, and the time has come for the PA profession to develop specialty-based publications as well. After we graduate PA school, many of us are inadequately prepared to work alongside resident- and fellowship-trained orthopedic surgeons. The didactic phase of most PA programs focuses little on orthopedic education, and a great deal of training occurs in clinical practice. Furthermore, most PAs choose to work in surgical subspecialties without the opportunity to develop a general orthopedic education. When I started at my practice 5 years ago, I quickly realized the substantial learning curve that myself and all new graduates face and for a long time my only goal was to keep my head above water. The more seasoned PAs in the practice saw patients independently and were treated as colleagues by our supervising physicians. This independence was earned by accruing enough knowledge and experience to make most patient care decisions independently. Like many PAs starting their careers in orthopedics, I was eager to learn and gain the respect of my supervising physicians. I began to understand how important continuing education is in our field. As my knowledge and experience grew, so did the mutual respect of my colleagues. Expanding my orthopedic knowledge has improved my ability to provide high-quality patient care. A publication our colleagues can contribute to and share will help us all grow academically and further recognize our specialty. The Journal of Orthopedics for Physician Assistants (JOPA) will promote a focused orthopedic education. JOPA strives to publish timely, clinically relevant, and readable content across all subspecialties. With the help of industry sponsors, JOPA has the potential to reach every PA practicing in orthopedic surgery. This is an exciting opportunity to create the first representing journal and unique academic resource for our colleagues. As we advance our knowledge, our patients and supervising physicians will further recognize the high level of care we provide. The success of JOPA will depend on contributions from others. Please visit our website (www. thejopa.org) or e-mail me at dcloutier@thejopa.org for further details. I thank everyone who contributed to the first issue of JOPA. Your effort made the journal a reality. Dagan Cloutier, PA-C JOPA Editor in Chief
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Osteoid Osteoma Case Study One Sean Hazzard, PA-C, Kevin Raskin, MD, and Peter Asnis, MD Massachusetts General Hospital, Boston, MA
A 19-year-old male presented to our sports medicine clinic with the chief complaint of right knee pain after an injury that occurred 9 months earlier. He was snowboarding when he went off a jump and miscalculated the landing, plummeting approximately 20 ft before landing on the ground. The patient did not fall down on impact, but landed the jump upright on the board. He denies feeling a “pop” or experiencing immediate swelling, but did have pain along the medial aspect of the tibia. He continued to snowboard a few more runs that day. The patient stated that he was sore for a week or two, but was bearing weight with minimal problems. One month after the injury, the pain began to increase without re-injury. He did not seek medical attention until 3 months after the injury. He was seen by another physician who obtained an MRI and was diagnosed with a subacute tibial plateau fracture. No other MRI abnormality was noted. The patient was placed in a long leg cast for 4 weeks before a follow-up MRI was obtained, showing unchanged findings. The patient was then placed in a hinged brace for 6 weeks.
FIGURE 1
He continued to have pain throughout this time during any type of weight bearing. His orthopedist provided a cortisone injection in the pes anserine bursa, but no alleviation of the pain resulted. Physical therapy was prescribed and performed, with no improvement. The patient was seen in our office for the first time 9 months after his injury, with complaints of generalized pain near the medial aspect of the proximal tibia with any amount of weight bearing. He could not return to strenuous activities. He denied swelling, buckling, locking, giving way, fever, chills, or sweats.
Examination The patient walked with a normal gait pattern. He was 5’9” and weighed 159 lbs. His knee had a neutral alignment, no effusion, normal skin, and no atrophy. His range of motion was 0-135 degrees with no pain exacerbated throughout this range. No medial or lateral joint line tenderness was found. Tenderness over the medial aspect of the proximal tibia near the area of the pes
FIGURE 2
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anserine bursa/medial tibial metaphysis was found. The extensor strength was 5/5. The knee was stable to Lachman, pivot shift, and anterior and posterior drawer tests, as well as varus/valgus stress testing at 0 and 30 degrees. A dial test was also negative at 30 and 90 degrees. The patient’s neurovascular status was intact. Radiographs of the right knee were taken the day of the exam and revealed that the joint spaces were well maintained. Radiographs showed 8-mm lucency in the right proximal tibial metadiaphysis with overlying mature periosteal new bone formation and thin reactive sclerotic borders, as well as a sclerotic central nidus (Figures 1 and 2). During the patient’s visit, the previously taken MRI films were not available, but radiology reports from the previous studies were. The first MRI was done 3 months post-injury and demonstrated extensive patchy and linear marrow edema throughout the medial proximal tibia crossing the fused physis. These observations were consistent with a subacute fracture extending to the tibial spine. The second MRI study was done 4 months post-injury and revealed a stable nondisplaced fracture of the proximal tibia with patchy edema throughout the proximal tibia, which did not substantially change from the original study. After we reviewed our radiograph findings, we referred the patient to an orthopedic oncologist, who obtained a subsequent MRI with contrast. The results were most consistent with an osteoid osteoma (Figures 3 and 4).
FIGURE 3
Treatment Treatment included radiofrequency ablation. Under CT guidance, a needle biopsy is performed, followed by introduction of a radiofrequency electrode through the biopsy hole, within the lesion, and heating of the tumor to 194°F for 6 consecutive minutes. Three weeks after the procedure, the patient was asymptomatic and expected to return to snowboarding within the coming weeks. He was able to resume full activities. Additional follow-up is pending. Authors have no relationship to disclose relating to the content of this article
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FIGURE 4
Osteoid Osteoma Case Study Two and Discussion Charles Dowell, PA-C, AT-C Rebound Orthopedics, Vancouver, WA
A 65-year-old female presented to the orthopedic clinic with a 6-month history of right low back, gluteal, and thigh pain. The patient is a nurse in an OB-GYN unit and gradually noticed increasing pain in the right leg. She described no history of injury or fall. She presented to the emergency room 2 months after the onset of pain for radiographs, which were read as negative. She was referred to a physiatrist, who repeated the radiographs (Figure 1), which were also read as negative. The physiatrist felt that the pain was radiating from her lumbar spine, and ordered an MRI of the lumbar spine and a bone scan. The MRI of the lumbar spine showed some facet joint arthritis at L4–L5 and L5–S1 on the right side. The bone scan was read as a possible stress fracture of the proximal lateral femoral cortex. Therefore, the patient was diagnosed with a stress fracture and told to remain non-weight bearing. The physiatrist gave the patient a prescription for NSAIDs, which she stated did improve her symptoms slightly, although the pain returned.
FIGURE 1
The pain significantly affected the patient’s daily activities as well as work. The pain was worse with standing and walking activities, and got progressively worse throughout the day. She also complained of night time symptoms that regularly woke her from sleep. The patient progressed to the point where she had to take time off work and began using crutches. She was referred to our orthopedic clinic at this stage. Her examination exhibited palpable tenderness directly over the posterior superior iliac spine and posterior sacroiliac joint, extending through her posterior ileum and iliac wing. The tenderness extended into the posterior gluteal and lateral greater trochanteric areas. She had increased pain with trunk flexion/extension and rotation to the right side. Passive range of motion of her hip with log roll, hip flexion, internal/ external rotation, and abduction/adduction did not cause pain. Resistive range of motion did cause pain with flexion and abduction against resistance. She had a negative straight leg raise. Her calves were soft and nontender, and she had a normal
FIGURE 2
neurovascular exam. Increased pain was elicited with any attempt to bear weight on the right side with single and double leg stances. This patient had an unusual presentation for a stress fracture, and her exam was inconsistent with this diagnosis. The radiographs did not show the typical transverse line seen in the area of cortical thickening that is consistent with a stress fracture. For this reason, she was sent for a CT scan (Figure 2) and an MRI (Figure 3) of her right hip and thigh. The results of these tests were inconclusive,
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FIGURE 3
as the radiologist read the MRI consistent with a stress fracture and the CT scan consistent with an osteoid osteoma. After discussion with our musculoskeletal radiologist, it was decided that MRI, CT, and bone scan were most consistent with an osteoid osteoma. With this unusual presentation and failure of non-surgical treatment, the patient was referred to an interventional radiologist for CTguided radiofrequency (RF) ablation. At the time of this article, the patient had not followed up with the interventional radiologist.
Discussion Osteoid osteoma is the most common benign bone-forming lesion and was first characterized by Jaffe in 1935. 1,2 It is the third most common benign bone neoplasm after osteochondroma and nonossifying fibroma,2 which most commonly occurs in persons aged 5–25 years, with a male:female ratio of 2:1. Its elective sites are the long bones, especially the femur and tibia, which are involved more than 50% of the time. Depending on their locations within the bone, osteoid osteomas can be distinguished into cortical (70–75% of cases), medullary (25% of the cases), subperiosteal, and intra-articular.4 The lesion is usually less than 1.5 cm in diameter and contains a discrete central area
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known as the nidus, which is surrounded by dense sclerotic bone tissue.3 The nidus is composed of thin seams of osteoid or woven bone lined with osteoblasts, which represents a process of bone remodeling with osteoblastic activity.3 The nidus is surrounded by a region of active bone formation that appears as sclerotic dense bone with various patterns of maturation.3 The nidus has been shown to be highly vascularized and contain abundant nerve fibers.2,4 These nerve fibers belong to the osseous nerve supply, which plays an important role in skeletal development and homeostasis.2 Osteoid osteomas usually present with a significant amount of soft tissue swelling around the area affected, and this may be secondary to the highly vascular nature of the tumor.2 Swelling may be mediated by production of prostaglandins, which can affect soft tissue and vascular permeability.2 Prostaglandin levels in the nidus are 100–1,000 times that of normal bone and are thought to be important in the perception of pain.2 The pain relief associated with NSAIDs has also been attributed to the inhibition of such prostaglandin production.2 Typical presentation includes localized pain that is frequently more severe at night. The pain may occasionally be relieved by NSAIDs. Depending on the location of the lesion, patients may also present with gait disturbances, bony deformity, joint stiffness or contracture, growth disturbances, swelling, and limb length discrepancies.2,3 In the case of limb length discrepancies, it was found that the involved extremity was typically the longer one.3 One possible explanation for limb overgrowth in children may be the resulting inflammatory response and associated hyperemia, especially in patients with lesions located near the open growth plate.3 Osteoid osteomas in complex sites such as the pelvis, posterior vertebrae, femoral neck, or hind foot can be difficult to diagnose radiographically.4 The classic finding on conventional radiography is an oval or round lucency (representing the nidus) with or without calcifications, surrounded by bone sclerosis and periosteal bone neoformation to different degrees.4 Bone scintigraphy demonstrates increased radionuclide uptake by the nidus.4 CT remains the method of choice to diagnose and locate the osteoid osteoma nidus, especially in complex anatomical sites.4 The characteristic appearance on a thinly sliced CT scan is of a lowattenuation nidus with central mineralization
and varying degrees of sclerosis surrounding the nidus.3 A recent report recommends the use of non-ionizing imaging modalities in children, although the role of MRI remains controversial.2 The appearance of the lesion on MRI may be highly variable, and the presence of associated soft tissue changes and bone marrow edema may result in diagnostic errors.3 Management is typically begun with salicylates or NSAIDs because of the abovementioned control of prostaglandins and pain relief. The time until symptoms subside with treatment using just these medications can vary from several months to several years. Surgical management may be warranted if the pain is too severe, the patient is unresponsive to medication, or the patient is unwilling to wait for the symptoms to spontaneously subside. Until the late 1990s, open excision with removal of the complete nidus was the only surgical option available.3 This was found to be highly effective, but sometimes the tumor was difficult to identify intra-operatively, and incomplete resection could result in recurrence.3 This method followed by a prolonged period of weight-bearing restriction if performed in one of the weight-bearing bones. CT-guided percutaneous resection, a less-invasive method, is performed with CT guidance to minimize the amount of excised bone and ensure that the entire nidus is resected.2 This is typically an outpatient procedure, but may require an overnight stay at the hospital. It is usually followed by restriction of activities for 4 weeks with toetouch weight-bearing if performed on one of the weight-bearing bones. RF ablation has been used successfully to treat osteoid osteomas for more than 20 years
and is currently the choice of treatment for most lesions.2,3 RF ablation is performed with the use of CT guidance, and the entire procedure generally takes 90 min.3 The RF electrode is inserted with the tip directed toward the nidus and thermal heating is applied for 4–6 min.2,3 The success rate for this procedure has been documented as high as 90%, only requires a brief recovery, and has a low complication rate.3
Conclusion Osteoid osteoma can be a challenging diagnosis if the patient does not present with classic symptoms. A differential diagnosis can include chronic osteomyelitis, stress fracture, nonspecific synovitis, arthritis, osteoblastoma, fibrous dysplasia, melorheostosis, or Ewing’s sarcoma.4 Diagnosis can be even more confusing, such as in our patient, with a presentation outside the typical age group and a non-specific appearance on bone scan and MRI. CT scan remains the modality of choice to diagnose the lesions and the characteristic nidus. Patients who appear with the typical throbbing pain that is worse at night and responds to NSAIDs can obtain a straight forward diagnosis. Currently, the treatment of choice remains CT-guided RF ablation, which has the highest success rate with the lowest recovery time and rate of complications. The author has no relationship to disclose relating to the content of this article
References 1. Shankman S, Deasai P, Beltran J.Subperiosteal osteoid osteoma: radiographic and pathologic manifestations. International Skeletal Society. 1997;26(8):457-62. 2. Laurence N, Epelman M, Markowitz R, et al.Osteoid osteomas: a pain in the night diagnosis. Pediatric Radiology. 2012;42(12):1490-1501. 3. Atesok K, Alman B, Schemitsch E, et al. Osteoid Osteoma and Osteoblastoma. J Am Acad Orthop Surg. 2011;19(11):678-689. 4. Cerase A, Priolo F.Skeletal benign bone-forming lesions. European Journal of Radiology. 1998;27:S91-S97.
Clinical Pearl Scapholunate advanced collapse (SLAC) is the most Sc common form of arthritis in the wrist. A wrist injury co causing scapholunate instability can lead to progressive ca degenerative changes and a SLAC wrist. de
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Combat Orthopedics My Experience During Operation Enduring Freedom Major Randall A. Pape, USAF PA-C
“Level one trauma in the ED, level one trauma in the ED, three patients.� This is what I heard for the past 6 months during my time spent at Craig Joint Theatre Hospital (CJTH) in Bagram Airfield, Afghanistan. I was very fortunate to use my training and experience as a physician assistant in orthopedics caring for our wounded warriors. I have been on active duty for 20 years and was lucky enough to be Major Randall A. Pape outside Craig Joint Theatre Hospital selected for the Interservice Physician Assistant program 14 years ago. After graduation, all PAs are commissioned as officers in facilities being in the more dangerous areas. We the Air Force and placed in primary care jobs. To received indirect fire in Bagram several times per specialize, PAs must apply to a very competitive month, and each time caused the alarm to sound board that meets once per year. After selection, and required everyone to don individual body PAs must complete a year-long fellowship before armor. being placed into a job using the new training. Upon The top priority of our medical team was to notification of a free, all expenses-paid trip to the respond to and care for wounded warriors. Most Middle East, there is more training to complete. patients arrived via Blackhawk helicopter or were Not only is there job-specific training, including a transferred in on a fixed-wing aircraft (military refresher course on trauma, but PAs must be replane). The wounded were initially cared for by qualified with their weapon(s) and on how to don their co-workers based on training they received a chemical suit and gas mask. prior to deploying. Many limb-saving tourniquets Here, I hope to provide a glimpse of what are applied in the field. The wounded are then often my job entailed in a combat setting. As the sole stabilized at a Role II facility manned by a general PA in orthopedics at CJTH, I had many duties surgeon, an orthopedic surgeon, an anesthesia and responsibilities. These included responding provider, an OR nurse, and a surgical technician. to trauma calls, being the first assistant in the The current survival rate of all patients who reach operating room, participating in daily rounds, CJTH is an astounding 98.6%. daily meetings, and weekly Afghan clinics, which Patients entered the trauma bay from the flight included caring for enemy prisoners, and being online through Warrior’s Way with an American flag call 24/7 for 6 months. draped across the ceiling. This was our way of CJTH is one of three Role III facilities in letting these patients know that they were entering Afghanistan. Two of these facilities are run by the an American facility. Here, they were immediately U.S. military and one is run by the British military. evaluated by the emergency department provider, CJTH is unique in that it is the hub of aero-medical either an emergency room doctor or an ER PA, and evacuation; therefore, all of the troops that are to a trauma surgeon. We evaluated the orthopedic be evacuated through the aero-medical evacuation injuries and triaged the patients for surgery. The system come through CJTH in Bagram. All of the orthopedic team consisted of three orthopedic hospitals are in the combat zone with the Role II surgeons, one orthopedic surgical technician, and
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AmbuBus delivering patients to the Emergency Department via Warriors Way me. As the orthopedic PA, I was responsible for working with the trauma surgeon to determine the order of patients based on severity of injury. Our orthopedic team would then divide and conquer, either with each of us working on a single patient or each of us taking an injured extremity on a single patient. This process was determined by the number of patients presenting during the trauma call. CJTH had three ORs, and each OR had the ability to serve two patients. This allowed us to take multiple patients into the OR at one time. The surgeries ranged from the all-too-common slamming of a hand in a mine-resistant ambush protected vehicle door, which weighs 900 lbs, to multiple limb amputations on a single patient. The multiple limb amputations usually occurred in the younger soldiers and marines, with the majority of such patients in their early 20s. We had one triple amputee who was a 4-year-old local national. He was playing on an improvised explosive device (IED) that his uncle had brought home when it exploded. Many of our patients required simultaneous care by providers in general surgery, urology, and vascular surgery. We were able to work together on the patient, always trying to stay out of each other’s way, or helping when required. I found myself often retracting for the general surgeon or cutting sutures for the urologist. Many of the patients for whom we cared were injured by a blast mechanism. My experience in Afghanistan was much different from my experience
in Iraq; many of our injuries in Afghanistan were dismounted (on foot) when injured by IEDs as opposed to mounted (in a vehicle) in Iraq. The dismounted IED injury wreaks havoc on the remaining soft tissues because the blast pattern carries the debris well up into the soft tissue. This injury requires a long and tedious debridement of the remaining soft tissue to help prevent infections. These patients often developed fungal infections that were very difficult to treat. It was not uncommon for these individuals to lose both lower extremities above the knee and a hand or some fingers on the lead arm that had carried the forward portion of their rifle. It was our job to meticulously clean these wounds and stabilize any fractures, usually with external fixators. Depending on the number of patients and the number of extremities that were injured, PAs were often responsible for the care of a single extremity, including application of external fixators . During my 6-month rotation, we operated on over 700 patients and more than 1,300 extremities. PAs in the deployed setting have more autonomy than those stationed in the states. Such PAs are required to do what it takes to help save lives and care for patients. Depending upon where a PA is stationed, the PA may be the patient’s only chance for survival. We refrained from implanting any hardware that would remain in the patient due to the increased risk of infection in Afghanistan. Wounds were either covered with negative-pressure dressings (wound vacuum-assisted closures, or VACs) or placed in special dressings that were soaked with Dakin’s solution periodically if a wound was at increased risk for fungal infection. After stabilization and recovery
IED Blast injury to the foot
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in the intensive care unit (ICU) or ward, patients were sent to Germany through our aero-medical evacuation system. From Germany, patients would move on to a large medical treatment facility near where they lived in the U.S. My other responsibilities consisted of lessthan-glamorous daily rounds and morning meetings. After our patients left the OR, they were signed out to either the ICU or ward. We were in constant communication with the physicians assigned to these areas. I was the point of contact for any questions regarding the orthopedic care of the patients in the ICU or ward . It was my responsibility to change dressings and fix any dressing problems, such as wound VAC troubleshooting, when necessary. The physicians and PAs met every morning to discuss the in-house patients and what their projected patient movements were. After the morning meeting, we visited each patient, discussing past and future care for each person. This was very important for our local national patients, whether they were Afghan National Army, Afghan National Police, or civilian patients . We got instant feedback about whether we were going to be able to care for each patient definitively or they were to be transferred to another facility. We also received updates on patients’ overall health and nutritional well-being. The majority of our Afghan patients were malnourished, which made for very difficult wound healing.
communicating with the prisoners because the interpreters stood behind a curtain so that they could not be identified and targeted later by these individuals. I was responsible for running the orthopedic service at CJTH. The teamwork in the combat setting was unparalleled, with all team members focused on getting the patients out of the OR as quickly and safely as possible so they could begin their long journey home. Keeping the surgeons available for the OR was of the utmost importance. Although this meant taking on all of the grunt work of meetings, rounds, dressing changes, and clinics, I believe there is nothing more rewarding professionally than caring for our nation’s wounded warriors. Hippocrates said, “He who wishes to be a surgeon should go to war.” After three trips there, I truly know what he meant. The author has no relationship to disclose relating to the content of this article
PAs were available, traumas permitting, for consultation on non-traumatic injuries. During my rotation, we were fortunate to have a sports medicine-trained family practice physician who handled most of these consultations, but some of the other deployed orthopedic PAs dealt with such consultations personally. CJTH also saw local nationals upon whom we had operated for follow-up 1 day per week. All communication with the local nationals was done through an interpreter. We often wondered if we were being told what the patient was actually saying or what the interpreter thought we wanted to hear. Usually, the same afternoon was spent evaluating consultations from the Afghanistan prison located in Bagram, which included many unusual cases, such as a prisoner who had the tip of his finger bitten off by another prisoner for pointing at the other prisoner and telling him to sit down and be quiet. It was even more of a challenge
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In Memory of Jerry “Buck” Pope October 1967 - October 2002 Husband, Father, Friend, Classmate died while deployed in Yemen
Share your Experiences with JOPA The Journal of Orthopedics for Physician Assistants (JOPA) provides a unique forum for sharing ideas and experiences with your colleagues. JOPA is the first journal representing the physician assistant orthopedic specialty and unique voice for all in the profession. We can all learn and grow from our shared experiences.
Image Quiz A 74-year-old female with a history of left-sided cerebrovascular accident presented to the emergency department with a 2-day history of left hip pain. She fell at home 2 days previously and chose not to seek medical attention initially because she thought the pain would improve. The patient lives with her son, who brought her to the emergency department for evaluation.
FIGURE 1. AP radiograph of the left hip
FIGURE 2. Frog leg lateral radiograph of left hip
Based on the radiographs above, what would be the next best choice of treatment for this patient? A. B. C. D.
Open reduction-internal fixation Intramedullary short nail Obtain a CT or MRI to check for occult fracture extension Nonsurgical: partial weight-bearing, 6 to 8 weeks Answer on page 21
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Procedures in Orthopedics:
Fluoroscopic Hip Injections Alan B. Johnston, PA-C New Hampshire Orthopaedic Center, Nashua, NH
Osteoarthritis of the hip is a common condition seen in most orthopedic practices. Other conditions such as femoro-acetabular impingment (FAI), labral tears, synovitis, and conditions affecting the lumbar spine can mimic hip arthritis. Various methods of treatment are available for these conditions, ranging from observation to surgical management. Our practice uses fluoroscopically guided intra-articular injections as an invaluable treatment option. With the addition of onsite magnetic resonance imaging (MRI) services to our practice several years ago, we researched and developed techniques to provide arthrography of the hip in conjunction with MRI. The options have since expanded to include intra-articular steroid injections for osteoarthritis and synovitis, aspirations for infection, and diagnostic injections to differentiate between intra-articular and extra-articular conditions, as well as injection techniques for the shoulder, elbow, wrist, ankle, and sacroiliac joints. With regard to the hip, the indication for intra-articular injections is short-term relief of pain, most commonly in the arthritic patient who is unwilling or unable to undergo arthroplasty. Contraindications for the procedure include allergies to contrast material, injectable anesthetics, or steroids. Relative contraindications include use of anticoagulation medications. Patients who are on aspirin therapy may proceed with intra-articular injection treatment. Patients taking other anticoagulants, including warfarin, clopidogrel, dabigatran, and the like, should stop use of the anticoagulant 5 days before the intra-articular injection procedure, if medically appropriate. Diabetic patients are cautioned about possible elevation of their blood sugar levels and are advised to adjust their medications accordingly.
PROCEDURE The patient dresses in a gown, with the opening toward the back. The patient is then placed supine on a radiolucent table. A bolster is placed under the ipsilateral knee to flex the hip. If the patient’s leg is in any external rotation, the feet are taped together to internally rotate the hip and provide a better image of the femoral neck. The anterior aspect of the hip is exposed and prepared with betadine and alcohol. After palpating the patient’s femoral artery, a sheathed needle is placed superior and lateral to the artery. The image intensifier is used to locate the injection entry site by adjusting the needle so that the tip of the needle is overlying the junction of the lateral femoral head and neck (Figure 1). The area is marked and the skin and subcutaneous tissues are injected with 5 ml 1% plain xylocaine. After satisfactory anesthesia is achieved, a 22-gauge spinal needle is introduced into the hip under direct fluoroscopic guidance. The needle is advanced parallel to the x-ray beam and perpendicular to the floor. It is imperative to keep the needle as parallel
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FIGURE 1
Procedures in Orthopedics:
Fluoroscopic Hip Injections to the beam as possible to avoid losing orientation. As the needle is advanced, some resistance will be met as it approaches the anterior hip capsule. The patient is warned that he or she may feel some mild discomfort as the needle is advanced through the capsule, especially patients with inflammatory conditions within the hip joint. As the needle is advanced through the capsule, contact should be made with the lateral femoral neck (Figure 2). Extension tubing is attached to the spinal needle, and contrast material (5 ml Isovue300 and 4 ml saline) is injected into the hip to confirm position. The needle should be stabilized during the injection to prevent it from being expelled from the hip joint by the inflow of fluid. A characteristic intra-articular filling pattern should be noted (Figure 3), and only the amount of contrast material needed to confirm position is used.
FIGURE 2
After intra-articular position is confirmed on the image intensifier, the needle is left in place with the extension tubing attached. The contrast syringe is removed and a syringe containing 6 ml 1% plain xylocaine and 80 mg Depo Medrol is injected slowly into the hip. The spinal needle is withdrawn, and a bandage is applied to the injection site after any bleeding is controlled. Post-injection instructions are given to the patient prior to departure from the fluoroscopy suite. Patients are advised that they may experience a sensation of fullness or mild discomfort secondary to capsular distention, which usually resolves after several minutes, and are also advised to limit unnecessary ambulation for 24–48 hours to avoid undue discomfort. Ice can be used at the injection site for local soreness from the needle puncture. Diabetic patients are again cautioned about possible elevation of blood sugar levels and advised to adjust their medications accordingly. Patients are seen back in the office after approximately 6 weeks for re-evaluation to determine their response to the injection. If successful, the injection may be repeated three to four times a year, so long as it remains effective.
FIGURE 3
SUMMARY In summary, intra-articular steroid injection with fluoroscopic guidance is an effective treatment option for various pathologies involving the hip. The technique is relatively safe and easy to master, and very well tolerated by the patient. To date, no infections, bleeding issues, or neural injuries have been reported at our facility, and we continue to perform these injections on a daily basis. The author has no relationship to disclose relating to the content of this article
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Lumbar Disc Herniation Dagan Cloutier, PA-C New Hampshire Orthopaedic Center, Nashua, NH
Travis Palmer, PA-C New Hampshire NeuroSpine Institute, Bedford, NH
Lumbar disc herniation is the most common surgical condition in patients presenting with radicular leg pain, with approximately 200,000 patients undergoing operative treatment each year.1 Lumbar herniated nucleus pulposus (HNP) presents symptomatically with a sudden or insidious onset of unilateral leg pain and is usually associated with an injury or precipitating event (often a forward bend and lifting maneuver, during which intradiscal pressure is high). Patients may also complain of intermittent back pain for months or years, with a recent aggravating event that worsens symptoms. Radicular pain usually extends below the knee and follows a dermatomal pattern, correlating with the nerve root involved. With lumbar disc herniation, symptomatic leg pain is more severe and frequent than low back pain. Standing, prolonged sitting, and Valsalva maneuvers can aggravate the pain. Lumbar HNP usually affects young and middle-aged adults, with a peak in those 35 to 45 years of age. As the nucleus pulposus ages, it loses water content and desiccates, and is less likely to herniate after the fifth decade of life.
younger adults are well hydrated and more likely to herniate. Lumbar roots below L1 are contained within the cauda equina and exit the neural foramen under the corresponding pedicles. For example, the L5 root traverses below the L4–L5 disc level and exits laterally under the pedicle of L5. The S1 nerve root traverses below the L5–S1 disc level and exits laterally under the pedicle of S1. Disc herniation can be classified by location into three anatomical zones of the spinal canal: central, paracentral, and foraminal. The central zone lies between the lateral borders of the cauda equina. The paracentral or posterior lateral zone extends from the lateral border of the cauda equina to the medial border of the pedicle. The foraminal zone lies between the medial and lateral borders of the pedicle. Extraforaminal disc herniations are located lateral to the border of the pedicle. Posterior to the disc space is the posterior longitudinal ligament (PLL). The PLL is an hourglass-shaped ligament, with the widest part located at the midline and thinning bands extending laterally. The superior lateral disc is left uncovered by the PLL, which explains why this location is the most common site of disc herniation. The location of the disc herniation will determine which nerve root is affected. Posterior lateral disc herniations generally affect the nerve
Anatomy Intervertebral discs are comprised of the nucleus pulposus, a firm, rubbery tissue that is surrounded by the ligamentous anulus fibrosus. Axial compression forces are transmitted to the nucleus and sustained circumferentially by the anulus. The nucleus pulposus lacks blood supply and nerve innervation, and relies on nutrients and oxygen that diffuse from the anulus fibrosus. Consequently, any injury to the nucleus pulposus will not heal. The anulus contains nerve innervation and may cause lower back pain with injury. The anulus also contains a blood supply that allows scar formation and healing after injury. Any disruption of the anulus can result in herniated disc tissue due to axial compression forces of the spine. Discs in
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FIGURE 1 Posterior Longitudinal Ligament. The red oval shows the location of a posterior lateral disc herniation.
Table 1. Exam findings in Lumbar Disc Disease
Level of HNP L1-L3 L3-L4 L4-L5
Root affected L2, L3 L4 L5
L5-S1
S1
Motor strength Hip Flexors Tibialis anterior Extensor hallucis longus Gastroc/ Soleus
S2-S4
S2, S3, S4
Bowel/ Bladder
root at the traversing level. The less-common lateral recess and foraminal disc herniations affect the exiting nerve root at the affected level. For instance, an L4–L5 posterior lateral disc herniation would affect the L5 nerve root. A foraminal herniation at that L4–L5 level would affect the L4 nerve root. The majority of herniations occur in the L4–L5 and L5–S1 levels.
Pathology Disc herniations can be classified as protrusion, extrusion, or sequestered. Disc protrusion (or disc bulge) is a symmetrical bulge around the circumference of the anulus, leaving the anulus intact. Disc protrusion may or may not impinge on a neurologic structure. The resulting pressure from the disc bulge on the innervated anulus can cause a significant amount of lower back pain, which is often referred to or diagnosed as discogenic back pain. A disc extrusion extends through an annular tear, but is still in partial continuity with the parent disc. An annular tear can cause significant back pain when it occurs, but after the pressure is relieved, the back pain usually subsides. A sequestered disc herniation is a fragment free from the parent disc within the spinal canal and prone to proximal and distal migration, usually only 1 or 2 cm. Spinal nerve root compression from HNP can cause moderate to severe radicular pain, decreased sensation, and motor weakness. However, nerve root compression from the disc pathology is not always symptomatic. Lumbar MRI commonly reveals asymptomatic disc pathology. Fewer than 6% of lumbosacral disc herniations become symptomatic.2 Symptomatic herniations are not always a result of direct neurologic compression. Chemical nerve root irritation plays an important role in radicular pain. Acute herniated disc material triggers the release of arachidonic acid and other
Sensation Anterior thigh Medial ankle Dorsum of foot
Reflex None Patella None
Posterior calf, plantar foot Perianal
Achilles Cremesteric
inflammatory mediators that encounter the nerve root, causing irritation.1
Exam Exam begins with observation of the patient’s pain level and any postural changes. Pain can worsen when disc space pressure increases during activities like walking, sitting, and standing. Lying reduces disc space pressure and usually improves pain. The patient often cannot sit still and constantly changes positions in an effort to find a more comfortable position. A complete neurological exam is necessary and should include testing of lower extremity motor strength, sensation, and reflexes. Muscle group weakness may be evident at presentation or several weeks after herniation occurs. Sensation is decreased almost immediately along a dermatomal pattern, correlating with the insulted nerve. Deep tendon reflexes are often depressed or absent in the affected muscle group. Provocative testing should be performed last because it will likely illicit pain. Straight-leg raise of the involved leg and the uninvolved contralateral leg may both illicit radicular pain. Radicular pain in the involved leg with straight-leg raise of the uninvolved leg is specific for herniation. Back pain alone with straight-leg raise is not a positive finding. Clinical findings of pain, decreased motor strength, and sensation are correlated with the nerve root affected (Table 1). A vascular exam, including palpation of dorsalis pedis and posterior tibialis arteries, should be performed. Vascular and neurogenic claudication can cause leg pain and reduced walking capacity. Neurogenic claudication has a gradual progression of symptoms compared to lumbar HNP and is more often caused by spinal stenosis and degenerative spondylolisthesis. Patients with spinal stenosis often complain
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FIGURE 2
Sagittal view of L5-S1 disc herniation
of worsening pain with spinal extension and significant relief with flexion, whereas herniated disc patients have more pain with spinal flexion and relief with extension. Testing for ankle clonus and Babinski’s will help rule out upper motor neuron pathology. Hip and pelvic pathology can cause referred pain to the back and lower extremities. Differential diagnoses that should be considered include hip osteoarthritis, iliotibial band syndrome, meralgia paresthetica, inguinal hernias, and sacroilitis. Obtaining a detailed history and performing a complete physical exam of the hip and lower extremities will help establish the diagnosis. Antero-posterior and lateral radiographs are initially taken to check for spondylolithesis, fracture, and foraminal stenosis. MRI is the diagnostic study of choice, as it clearly delineates size, type, and location of a disc herniation. An MRI can differentiate other causes of radicuar pain, such as primary tumor or metastatic disease and bony compression. Symptoms of night pain or previous history of cancer should warrant MRI, even in case of negative initial radiographs. Computed tomography myelography can be used when MRI is contraindicated, such as in patients
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FIGURE 3 Axial view of left posterior lateral disc herniation
with pacemakers. This form of imaging is also helpful in patients with prior spinal surgery with instrumentation. Gadolinium-enhanced MRI should be performed in patients with a history of previous level surgery or when recurrent disc herniation is suspected. Contrast enhancement helps differentiate disc herniation from postoperative scar tissue causing neural impingement. Electromyography can help differentiate radicular symptoms from peripheral neuropathy or upper motor neuropathy. Any presentation of urinary retention, urinary or fecal incontinence, saddle anesthesia, and bilateral radicular symptoms should raise concern of possible cauda equina syndrome (CES).
Cauda equina syndrome (CES) CES occurs in only 2% of lumbar HNPs and is usually caused by a large central lumbar disc herniation. The cauda equina includes the peripheral nerve roots L1–S5 located within the dural sac. Compression of these roots causes symptoms of a lower motor neuron lesion, such as muscle weakness, decreased sensation, and decreased or absent reflexes.
Onset of symptoms can be rapid or slowly progressive. Symptoms unique to CES include perigenital, perirectal, or “saddle� anesthesia and loss of bowel or bladder control. Bladder dysfunction is a required symptom for diagnosing CES. Motor loss can start with subtle difficulty initiating the urinary stream with progression to urinary retention and eventual overflow incontinence. Decreased rectal tone can be an early sign of CES, and a rectal exam is important in establishing the diagnosis. Preferable treatment is decompression via discectomy within 24 h of symptoms to prevent progression of neurological deficits. Although timing of surgery is still under debate, evidence shows that there is a significant difference in the resolution of motor and sensory deficits postoperatively with treatment within 48 h.3
Treatment Herniated lumbar discs affect 2% of the population. Seventy-five percent of these patients are asymptomatic after 6 weeks, and 90% are symptom-free at 3 months . Resolution of motor weakness is seen with 80% of patients after 6 weeks, 90% after 12 weeks, and 93% after 24 weeks.2 The natural history of lumbar disc herniation is eventual disc resorption and resolution of symptoms. Conservative care with rest and antiinflammatory medications are initiated early. A Medrol DosePak, which can include a 6-day tapering course of 4 mg methylprednisolone with six tablets on the first day and one tablet on the last day, is commonly prescribed. Patients should be advised that there is less than a 10% chance of significant symptoms beyond 3 months. Physical therapy should be started to strengthen core muscles when symptoms tolerate. Transcutaneous electrical nerve stimulation (TENS) units are commonly used in the therapy setting for pain relief. Narcotics and muscle relaxers are used cautiously to prevent dependence. Lumbar epidural steroid injections (ESIs) have increasingly been used as a low-risk alternative to surgical intervention for patients who failed conservative treatment. Steroids inhibit the inflammatory response caused by disc chemical irritation and mechanical compression. Common injection techniques include interlaminal and transforaminal approaches. Transforaminal
injections target the anterior epidural space closest to the nerve root pathology. Interlaminal injections deliver fluid into the posterior epidural compartment, with hope that it will flow to the insulted nerve root.4 Transforaminal approaches require fluoroscopic guidance for safe and accurate placement. Butterman reported on the efficacy of treatment with ESIs in surgical candidates with lumbar disc herniation. Nearly one-half of the patients who received ESIs had a decrease in symptoms. The degree of improvement was similar to the results seen in patients who underwent discectomy. The study also reported that delaying surgery for an initial trial period of ESIs was not detrimental to neurological recovery.5 Contraindications for ESIs include local or systemic infection, anticoagulation, contrast dye allergy, and previous spine surgery at that level.
Spine Patient Outcome Research Trial (SPORT) The Spine Patient Outcome Research Trial (SPORT) was a prospective, multicenter study funded by the National Institutes of Health that examined surgical vs. non-surgical outcomes for intervertebral disc herniation, spinal stenosis, and degenerative spondylolisthesis. SPORT was one of the first comprehensive studies of the efficacy of surgery for lumbar disc herniation. The variable discectomy rates within regions of the United States and the lower rates seen internationally raise concern about the appropriateness of surgical decision-making. SPORT was designed to address these concerns and provide information on how to best treat lumber disc herniation. Candidates from 13 spine clinics across 11 states with image-confirmed lumbar disc herniation were randomized into one of two groups: operative treatment and non-operative treatment. Patients included 501 surgical candidates with imageconfirmed lumbar disc herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks. Weinstein et al. reported that patients in both the operative treatment group and nonoperative treatment group improved substantially over a 2-year period. Due to the large patient crossover between treatment groups, the intentto-treat analysis showed no statistically significant
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differences between the two groups. Although not significant, differences in improvements were consistently in favor of surgery for all outcomes and at all time periods. The pattern of crossover between treatment groups suggested the intentto-treat analysis underestimated the true effect of surgery.6 In 2008, Weinstein et al. reported on results between groups at 4 years. Patients who underwent surgery achieved greater improvement than the non-operatively treated patients in all primary and secondary outcomes except for work status.7 Several other studies based on the SPORT data have been published. Radcliff et al. investigated the effect of ESIs on primary outcome scores and how ESIs influenced operative vs. non-operative treatments. Results showed no significant differences in outcome scores between patients who received ESIs and patients who did not at years 1, 2, 3, and 4. However, the study showed an increased rate of surgical avoidance in the group who received ESIs. The study reported a 41% rate of crossover by surgically assigned patients who received ESIs, compared to a 12% rate of crossover by surgically assigned patients who did not receive ESIs.8 Rihn et al. examined symptom duration and how timing of treatment influenced outcome. The study concluded that increased symptom duration beyond 6 months due to lumbar disc herniation was related to worse outcomes for patients in both the operative and non-operative groups. The increased relative benefit of surgery compared to non-operative treatment was independent of the duration of symptoms.9
Operative Treatment The main surgical indication for lumbar disc herniation is unremitting radicular pain. Motor weakness caused by lumbar disc herniation will resolve in most cases and is not an indication for surgery. Only when motor weakness is disabling and associated with severe pain or progresses rapidly is surgery indicated. There is no evidence to support that surgery improves the recovery of motor weakness better than conservative care in the short-term or long-term. Residual motor weakness postoperatively is correlated with the severity and duration of motor symptoms preoperatively.2
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MRI will confirm the level and location of disc herniation, which should correlate with the patient’s physical signs and symptoms. Timing of surgery is a source of ongoing debate. Paul et al. reported that early surgery after a failed conservative treatment period of 6 weeks offered significant benefits over non-operative treatment in the early follow-up period. The maximum surgical benefit was seen at 8 to 12 weeks postoperatively. However, at years 1 and 2, no differences existed between operative and non-operative groups in primary outcome measures.10 Therefore, patients should be educated on the benefits of surgery in the short-term, as longterm benefits are less proven. A patient’s treatment preference may be influenced by factors such as the desire to return to work, litigation involvement, workers compensation, and psychological issues. All factors should be considered when determining the most appropriate treatment choice for each patient. Lumbar discectomy has been performed for over 70 years and open microdiscteomy is the most common technique performed today. Minimally invasive procedures attempt a smaller incision, limited foraminotomy, and removal of displaced disc tissue. The most common approach to the lumbar spine for lumbar discectomy is a posterior midline approach. The patient is placed in a prone position on a radiolucent table (such as a Jackson or Andrew’s table). Preoperative and intraoperative radiographs or fluoroscopic images are taken to guide the surgical approach to the correct level of pathology. The most common complaint in litigation cases against spine surgeons is wronglevel surgery, so identifying the correct level of pathology before and during the surgical approach is essential. After the correct level is confirmed, a standard laminotomy or partial laminectomy is performed to adequately visualize the pathology. Gentle retraction of neural elements will allow visualization of the of disc material for removal. An anulotomy or incision through the posterior longitudinal ligament and anulus fibrosis can be performed to access remaining herniated disc tissue. A dose of 1 ml DepoMedrol® (80 mg) may be applied to the affected nerve root for further postoperative relief prior to closure. Patients are often admitted postoperatively for observation overnight, but surgery is also
performed in outpatient settings. Patients generally experience improvement or resolution in leg pain within 24 hours and often wake up from surgery with dramatic relief. Any postoperative headache should raise concern of a dural tear; patients with these complaints should be kept supine until symptoms improve. Activity includes slow progressive walking and activities of daily living as tolerated, starting immediately. The patient should be educated on postoperative restrictions, including no bending or lifting over 10 lbs and no twisting. Physical therapy for core strengthening may begin anywhere between 2 and 6 weeks, with extension exercises encouraged initially. Long car rides and heavy lifting should be avoided for 3 months. Success rates including pain relief from surgery are greater than 90%. Recurrent herniation, as defined by
herniation after a pain-free period of 6 months, can occur in 5 to 15% of patients.2 Authors have no relationship to disclose relating to the content of this article References 1.Lee JK, Amorosa L, Cho SL, Weidenbaum M, Kim Y. Recurrent lumbar disc herniation. J Am Acad Orthop Surg. 2010; 18(6): 327-37. 2.Sharma H, Lee SW, Cole AA. The management of weakness caused by lumbar and lumbosacral nerve root compression. J Bone Joint Surg Br. 2012; 94(11):1442-7. 3.Darden B, Kim D, Madigan L, Rhyne A, Spector LR: Cauda equina syndrome. J Am Acad Orthop Surg. 2008; 16(8):471-9. 4.IA, Hyman GS, Packia –Raj LN, Cole AJ: The use of lumbar epidural/transforaminal steroids for managing spine disease. J Am Acad Orthop Surg. 2007; 15(4): 228-38. 5.Butterman GR. Treatment of lumbar disc herniation: epidural steroid Injection compared with discectomy. A prospective, randomized study. JBJS 2004; 86(4): 670-9. 6.Weinstein JN, et al: Surgical vs nonoperative treatment for lumbar disc herniation. The Spine Patient Outcomes Research Trial (SPORT) A Randomized Trial: JAMA. 2006; 296(20): 2441-2450. 7.Weinstein JN, et al: Surgical versus nonoperative treatment for lumbar disc herniation: four year results from the Spine Patient Outcome Research Trial (SPORT). Spine. 2008; 33(25): 2789-2800. 8.Radcliff K, et al. The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation A subgroup analysis of the SPORT Trial. JBJS. 2012; 94(15): 1353-8. 9.Rihn JA, et al. Duration of symptoms resulting from lumbar disc herniation: Effect on treatment outcomes analysis of the Spine Patient Outcomes Research Trial (SPORT). JBJS 2011; 93(20): 1906-14. 10.Peul WC, Arts MP, Brand R, Koes BW. Timing of surgery for sciatica: a subgroup analysis alongside a randomized trial. Eur Spine J. 2009; 18(4): 538-45.
Image Quiz Answer Answer: C. AP and lateral radiographs (Figures 1 and 2) show a left greater trochanteric fracture. Isolated fractures of the greater trochanter usually result from direct impact. Controversy exists as to the best way to treat isolated greater trochanteric fractures. It is difficult to establish a definitive diagnosis when plain films cannot rule out a possible occult fracture extension. CT or MRI should be considered to rule out fracture extension; if negative, immediate weight-bearing as tolerated can be initiated. Follow up radiographs should be obtained to monitor for displacement secondary to the pull of the gluteus medius and gluteus minimus muscles.
FIGURE 3 CT image of the left hip. No fracture extension is seen through the trochanteric region.
FIGURE 4 CT image of the left hip showing the isolated greater trochanteric fracture.
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Normal / Abnormal Image Review: Rotator Cuff Tears Heather Killie, MD - New Hampshire Orthopaedic Center, Nashua, NH
NORMAL
FIGURE 1
ABNORMAL
FIGURE 2
Figure 1 is a normal coronal image of the right shoulder. Figure 2 (yellow arrow) shows an insertional tear at the distal supraspinatus tendon. There is extension into the footprint, likely indicating a subtle full thickness tear.
FIGURE 3
FIGURE 4
Figure 3 is a normal coronal image of the right shoulder. Figure 4 shows a large full thickness retracted supraspinatus tear (yellow arrow), with fatty atrophy (blue arrow). There is evidence of supraspinatus muscle volume loss.
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NORMAL
FIGURE 5
ABNORMAL
FIGURE 6
Figure 5 is a normal sagittal image of the left shoulder. Figure 6 shows a full thickness supraspinatus tear with a yellow arrow indicating the absent tendon at the greater tuberosity footprint . The red arrow points to the subscapularis tendon, the blue arrow to the infraspinatus tendon and the green arrow to the teres minor tendon.
FIGURE 7
FIGURE 8
Figure 7 is a normal axial image of the right shoulder. Figure 8 shows a subscapularis tear with the yellow arrow pointing to the free tendon edge. The subscapularis muscle belly appears attenuated (blue arrow). There is slight subluxation of the biceps tendon (red arrow).
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Writing for JOPA: Information for Authors The Journal of Orthopedics for Physician Assistants (JOPA) is a peer-reviewed publication that delivers a broad range of orthopedic content across all subspecialties. Authors can contribute any original article that promotes an orthopedic education for physician assistants (several examples are listed below). JOPA avoids publishing original research and industry-sponsored articles, as well as articles previously published or being considered for publication in other journals. Articles are peer reviewed by a panel of orthopedic physicians and PAs to ensure accuracy, clinical relevance, and readability. References should be cited using the AMA Manual of Style, 10th edition. References should be recent and predominately drawn from peer reviewed journals. Textbook and website references should be avoided if possible. Article content, including the manuscript body and any tables, should be submitted in Microsoft Word format to facilitate editing. Please use a standard font, such as Times New Roman, and a 12-point font size. Use appropriate headings and subheadings in feature articles to organize paragraphs. JOPA reserves the right to edit content for space and/or grammar issues. Any images that accompany an article must be sent as separate downloadable files from the manuscript text for publishing.
Featured Review Articles Featured review articles should contain a comprehensive review of literature on an orthopedic topic of choice. These academic literature reviews should be heavily referenced and may be co-authored. Subspecialists should consider writing on topics in their fields of expertise. Featured review length should be 4-8 pages. When considering the appropriate length, keep in mind the clinical significance and readability of content.
Review Articles Review articles should be 3-4 pages on an orthopedic topic of choice. Review articles should be selective and include few references. Authors may review a clinical condition, surgical procedure, or any other topic related to orthopedics. Preceptors may consider co-authoring a review article with a PA student interested in pursuing a career in orthopedics.
Case Studies Case studies choose a case and provide a complete history of the clinical presentation, treatment, and outcome. Radiographs and other imaging should be included to follow the course of a diagnosis and treatment. Several learning points should be included at the end of the case study, with appropriate references. Please remove all patient identification information prior to submission.
Case Reviews and Image Quizzes Case reviews present a unique case with several images and a brief description of the presentation, diagnosis, and treatment. Image quizzes include an image for
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readers to interpret. Answers should be provided, with a brief explanation of the patient and correct diagnosis. Do not include literature review or references for case reviews or image quizzes.
Be Creative! Consider submitting a description of how your practice uses PAs or the relationship you have with your supervising physicians. Consider writing on a patient’s experience and how it could be of value to PA colleagues. Write a detailed narrative of a typical day in your life as a PA. Personal experiences can be some of the most interesting and helpful articles for other PAs to read. If you have any other submission ideas, please contact the editor at dcloutier@thejopa.org.
Supervising Physicians and Allied Health Professionals Supervising physicians may submit articles on topics in their subspecialty or issues related to the PA profession. Physicians may also choose to write on a procedure or service unique to their practice. Co-authoring an article with a supervising physician is a great way to promote the physician-PA relationship. Nurse Practitioners practicing in orthopedics are encouraged to contribute, and may receive a free copy of JOPA by contacting the editor or subscribing online. Contributions from other allied health professionals, such as physical therapists and athletic trainers, give PAs an opportunity to learn from those with whom we share patient care responsibilities. Allied health professionals who wish to contribute to JOPA can contact the editor, Dagan Cloutier, at dcloutier@thejopa.org.
Test Your Knowledge Quiz Questions and Answers can be found at thejopa.org 1. A radial shaft fracture with associated DRUJ dislocation is referred to as: A A. Mais Maisonneauve B. Galeazzi’s C. Monteggia’s D. Essex-Lopresti
2. A patient with right radicular arm pain has a weak triceps reflex and decreased sensation of the middle finger on exam. Which cervical root is most likely being impinged? A. C5 B. C6 C. C7 D. C8
3. The classification for an 8-cm open crush injury to the distal tibia with fracture, moderate contamination, and adequate soft tissue coverage for closure is: A. Type 2 B. Type 3a C. Type 3b D. Type 3c
4. Another name for calcaneal apophysitis is: A. Osgood-Schlatter disease B. Sever’s disease C. Ollier disease D. Freiberg’s disease
5. Which type of suture is non-absorbable? A. Monocryl B. Vicryl C. Polydioxanone (PDS) D. Prolene
6. What Salta-Harris type is a fracture through the epiphysis and physis, but sparring the metaphysis? A. 3 B. 2 C. 1 D. 5
7. Which is the best description of a Garden Type 1 femoral neck fracture? A. Varus impacted B. Valgus impacted C. Complete displacement D. Stress reaction
8. Which shoulder test is indicative of a SLAP lesion? A. Yergason’s B. Speed’s C. O’Brien’s D. Neer’s
9. What is the most common pediatric bone tumor? A. Osteochondroma B. Osteoid osteoma C. Giant cell tumor D. Chondroma
10. A 46-year-old female runner has MRI findings of a stress reaction with tension sided edema to the left femoral neck after several months of intense training. What is the next best step in treatment? A. Non-weight bearing for 6-8 weeks B. Cannulated screw fixation C. Weight-bearing as tolerated, but avoid further running D. Hemiarthroplasty
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Infectious Diseases Consult Factors Influencing Antibiotic Choice for Acute Osteomyelitis Kirthana Raman, PharmD Tufts Medical Center, Boston, MA
Despite vast advancements in surgical and pharmacologic treatments, osteomyelitis (OM) remains a problematic infection. Several factors contribute to OM’s chronicity and inability to be eradicated. The largest barrier to treatment is the lack of adequate vascularization within bony tissue. Without sufficient vascularization, pharmacologic therapies cannot reach the site of infection at reasonable concentrations. Necrotic OM also destroys the minimal vasculature that exists, further diminishing antibiotic migration to the site of infection. Furthermore, vascular disease is often present in patients with OM, creating another barrier to the achievement of therapeutic antibiotic concentrations at the site of infection. Although the ability to medically eradicate OM is hotly debated, it is evident that a combination of surgery and antibiotics is necessary for therapeutic improvement, and we should optimize the use of specific antibiotics (in terms of spectrum, pharmacokinetics, and tolerability) to give patients the best chance at improvement. More than one-half of OM cases are caused by Staphylococcal species, including methicillinresistant Staphylococcus aureus (MRSA), methicillinsusceptible Staphylococcus aureus (MSSA), and coagulase-negative Staphylococcus species. Other less common but clinically relevant organisms include other gram positive organisms like Streptococci or Enterococci, as well as gram negative organisms like Pseudomonas, Enterobacter, Proteus, Escherichia coli, and Serratia. For necrotizing or rapidly progressing infections, anaerobic organisms like Clostridium species and Bacteroides fragilis should be considered. Patients with diabetes, especially those with diabetic foot infections, are likely to have polymicrobial infections and are prone to infections with Streptococcus. Polymicrobial infections are also found in patients with decubitus ulcers, penetrating trauma from a dirty source, and necrosing OM. If a patient has undergone multiple courses
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of broad-spectrum antibiotics, resistant gram negative rods, including Pseudomonas, should be considered. OM associated with surgical site infections or hardware is most likely due to a gram positive organism like Staphylococcus or Streptococcus species, but gram negative organisms may be involved in certain clinical situations. Bite wounds, most commonly cat bites, can cause OM associated with Prevotella species. Using microbiological cultures will aid in pathogen-directed therapy. Blood cultures will commonly be positive for the causative pathogen after radiographic diagnosis of OM. Bone cultures obtained operatively will usually be positive for OM, as long as antibiotics were withheld prior to surgery.1 If cultures are negative, therapy should include antibiotics aimed at the most likely pathogens, including Staphylococcus species. Antibiotic choice should always incorporate concepts like spectrum of activity (coverage of the fewest possible organisms to prevent superinfections or resistance), patient tolerability (OM treatment requires weeks to months of therapy), and bone penetration. Vancomycin (Vancocin) is the most common antibiotic used for OM treatment. Vancomycin is an inexpensive intravenous (IV) antibiotic that is bactericidal against gram positive species, including all Staphylococcal species. It does not have activity against any gram negative organisms. Due to its spectrum of activity, vancomycin can be used for culture-proven gram MRSA infections. In combination with fluoroquinolone or a betalactam, vancomycin provides broad gram positive and gram negative activities for polymicrobial infections. Vancomycin is accompanied by a myriad of adverse effects, most notably nephrotoxicity. The risk of vancomycin nephrotoxicity is thought to be highest with high doses of vancomycin (>4 grams per day), prolonged courses (> 14 days), concomitant nephrotoxins, and baseline kidney disease. Although vancomycin is commonly used for OM, its penetration into bone is suboptimal. Bone concentrations of vancomycin have been measured between 5–40% of serum levels, with
variations by time after dose, type of bone, and variations in sampling/assaying.1 Although the measured bone levels were relatively low, there have been numerous documented successes with the use of vancomycin for OM. Clindamycin (Cleocin) is an antibiotic that has been used to treat OM for over 40 years. Clindamycin is available in oral and IV formulations, and is effective against gram positive and anaerobic organisms. Like vancomycin, clindamycin does not have activity against gram negative organisms. It is generally well tolerated by patients but can cause diarrhea or rash. Additionally, due to its availability as both an oral and IV medication, patients can be easily transitioned off IV antibiotics. Clindamycin is considered to have good bone penetration, with concentrations ranging between 21 and 45%
of serum levels.1 Higher concentrations have been achieved in infected bone compared to healthy bone. Although a more traditional agent, clindamycin remains a mainstay in OM therapy, either alone or in combination with a gram negative agent like a fluoroquinolone or tetracycline.
Fluoroquinolones including levofloxacin (Levaquin), ciprofloxacin (Cipro), and moxifloxacin (Avelox) have gained favor over the past few decades in OM therapy. All of the fluoroquinolones have broad gram positive and gram negative activities. None of the fluoroquinolones have activity against MRSA or coagulase-negative S. aureus. Levofloxacin and ciprofloxacin have activity against some multi-drug resistant gram negative organisms, and moxifloxacin has activity against anaerobic organisms.
Table 1. Empiric Therapy Options Risk Factor
Likely Organism
Empiric Treatment Options
Hematogenous
Staphylococcus aureus
Oxacillin 2g IV q 4-6 h Vancomycin 15-20 mg/kg IV q 8-12 h Daptomycin 6 mg/kg IV once daily Linezolid 600 mg orally or IV twice daily Clindamycin 600 mg orally or IV q 8 h
Diabetes, Vascular Insufficiency
Group B Streptococcus
Ampicillin 2g IV q4-6 h
Polymicrobial
Vancomycin 15-20 mg/kg IV q 8-12 hÂą Ciprofloxacin 400 mg IV q 12 h or 500 mg PO q 12 h
Open fractures
S. aureus Pseudomonas aeruginosa E. coli
Ciprofloxacin 400 mg IV q12h or 500 mg PO q 12 h Âą Vancomycin 15-20 mg/kg IV q 8-12 h
Hardware Infection
S. aureus, Coagulase negative Staph
Vancomycin 15-20 mg/kg IV q 8-12 h
IV Drug Use
S. aureus Streptococcus spp. Oral Anaerobes (if licks needles)
Ampicillin/ sulbactam 3g IV q 6 h
Foot puncture with soaking / moisture
Pseudomonas
Piperacillin/ tazobactam 3.375g q 6 h (or q 8 h if administered over 4 h infusion)
Human bite
Oral anerobes, Eikinella spp., Viridans group Streptococcus
Ampicillin/ sulbactam 3g IV q 6 h Cefoxitin 1g IV q 6-8 h Ertapenem 1g IV q 24 h
Animal bite
Pasturella multocida Bartonella henselae
Ampicillin/ sulbactam 3g IV q 6 h Ertapenem 1g IV q 24 h Doxycycline 100 mg IV or PO q 12 h
Sickle cell
S. aureus Salmonella spp.
Ciprofloxacin 400 mg IV q 12 h or 500 mg PO q 12 h
* Suggested Treatment of Acute Osteomyelitis is 4-6 weeks duration. Transition from IV to oral antibiotics is based on clinical stability. De-escalation to a narrow-spectrum antibiotic should be performed on receipt of culture results.
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Long-term or frequent use of fluoroquinolones, although well tolerated, has been linked to an increase in gram negative resistance. All of these agents can cause nausea and diarrhea, and have all been rarely linked with tendon rupture and sudden cardiac death. In patients without cardiac disease, fluoroquinolones are well tolerated and only require dosing once or twice per day. Fluoroquinolones are all available in IV and oral formulations, facilitating IV transition, and are all relatively inexpensive. All of these agents have very high bone penetration, reaching bone concentrations between 40 and 120% of serum levels. When measured separately, there are higher levels in cancellous bone than in cortical bone.1 Fluoroquinolones remain a reliable option for pathogen-directed or empiric broad-spectrum OM treatment.
These agents are generally inexpensive, relatively well tolerated, and can be used over a long period of time without serious consequences. Approximately 10% of the population reports allergies to beta-lactam antibiotics; however, only 1% of the population has a true allergy. The fraction of bone penetration is relatively low, at 10 to 30% of serum levels; however, serum concentrations of beta-lactams are often much higher than needed and low penetration of such high concentrations may be sufficient for effective therapy.1 Therefore, penicillins and cephalosporins are often a first-line option for broad empiric and pathogen-directed therapy of OM. Treatment of OM is complex and requires thoughtful interventions. When treating a patient with OM, a combination of antibiotics and surgical intervention is necessary for effective therapy. However, these patients are rarely critically or acutely ill, and orthopedists are urged to postpone antibiotic initiation until after surgical intervention and after cultures are obtained to optimize microbiologic findings. When initiating therapy, clinicians should take care to incorporate multiple factors, like tolerability, spectrum of activity, and bone penetration.
Penicillins and cephalosporins (beta-lactam antibiotics) are some of the oldest antibiotics available and have been used extensively in the treatment of OM. These agents vary greatly in their spectrum of activity, from penicillin (narrowest) to cefepime (broadest), with some available for oral administration and some IV. Most beta-lactams have activity against MSSA and Streptococcal species. Only the newest cephalosporin, ceftaroline (Teflaro), has activity against MRSA and coagulase-negative S. aureus.
The author has no relationship to disclose relating to the content of this article Reference 1.Landersdorfer CB, Bulitta JB, Kinzig M, Hozgrabe U, Sorgel F. Penetration of Antibacterials into bone: Pharmacokinetic, Pharmacodynamic, and Bioanalytical Considerations. Clin Pharmacokinet. 2009; 48(2): 89-124.
Join the JOPA Editorial Board All articles submitted to JOPA are reviewed by the Editor in Chief, who is responsible for deciding whether an article is accepted, rejected, or in need of revision before publication. JOPA will be forming an editorial board by subspecialty. Each subspecialty section will be represented by a physician assistant or section editor whose knowledge and experience lies within the chosen subspecialty. Each section editor will review submitted articles within their subspecialty prior to publication and send articles to a group of peer reviewers who share knowledge and experience in the subspecialty. Once peer reviewed, authors will have the opportunity to revise their article and re-submit for publication. This will ensure that all articles published in JOPA are accurate, clinically relevant, and readable. Anyone interested in joining the editorial board should email, Dagan Cloutier, Editor in Chief, at dcloutier@thejopa.org.
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Subspeciality Sections • • • • • • • •
Hand Spine Trauma Arthroplasty Sports Foot and Ankle Pediatrics Tumor
Preoperative Decolonization of MSSA/MRSA Nasal Carriage and the Effect on Orthopedic Postoperative Surgical Site Infections Joshua Radi, PA-C Loyola University Medical Center, Maywood, IL
Postoperative surgical site infections (SSIs) are a major factor in the morbidity and mortality in patients undergoing elective or non-elective orthopedic surgery. The most common pathogenic organism in such cases is Staphylococcus aureus.1,2 Although this gram-positive bacterium is a part of the natural flora in most individuals, it can become pathogenic in some hosts. As over-prescribing and under treatment with antibiotics has increased, the level of antibiotic resistance in microorganisms such as S. aureus has also increased. S. aureus primarily colonizes the nares, axillae, and groin, but can occur at any topical site on the body. The carrier rate of S. aureus in the nares of the general population ranges from 20-30%,16,26-31 with 3% of these cases due to methicillin-resistant Staphylococcus aureus (MRSA).2-3 The Veterans Affairs population has MRSA nasal colonization rates approaching 7%.13 The S. aureus isolated from the nares and postoperative surgical wounds tends to be identical.19 A direct epidemiological link is present between S. aureus in the nares and the development of S. aureus SSI.16-19 Of these S. aureus SSIs, patients with preoperative positive nasal MRSA colonization have an increased risk of postoperative MRSA infection compared to those without colonization.3,20-25 One major risk factor for MRSA colonization is a recent hospital admission.14-15 One study evaluating the prevalence of MRSA carriage in trauma and orthopedic patients showed that 4% of patients are negative for MRSA on admission, but are positive on discharge.3 Another study of 20,000 mixed surgical patients showed that 57% of infected patients are not colonized with MRSA during admission but acquire MRSA infections during their hospitalization.4
the surgical field. Seeding through the bloodstream is another potential route for SSI.6-7 SSIs can have devastating consequences. For example, based on United States data from the National Inpatient Sample database, 25% of total knee revisions are performed because of infection.8 Treatment may require a two-stage revision surgery: removal of hardware, placement of antibiotic spacers, and 6-8 weeks of intravenous (IV) antibiotics, followed by removal of the antibiotic spacer and revision surgery after the initial infection is eradicated. Some studies show that the cost of revision surgery in total joint arthroplasty (TJA) due to infection approaches four times the cost of a primary TJA.9-11 Up to 25% of such SSIs may not be clinically evident until 2 years after the initial operation.12 Improvements in patient surgical site preparation, sterility precautions in the operating room, and use of perioperative antibiotics have reduced elective orthopedic SSIs to an average of below 2%.12-13 Additionally, many institutions have protocols that place patients who screen positive for MRSA in isolation with contact precautions. Such protocols have significantly decreased the rate of infection and may be one of the most important measures in preventing infection.56-57 These precautions reduce patient-to-patient transmission in the hospital by health care workers and underscore the importance of proper hand washing or use of alcohol-based rubs. Although the rates of postoperative SSI have decreased, the goal is to reduce this infection rate further. Nasal S. aureus carriage is thought to be an important risk factor for SSI, suggesting that preoperative nasal decolonization could play a role in reducing these infections.32
DECOLONIZATION MRSA IN ORTHOPEDIC SSI The prevalence of MRSA in deep orthopedic SSIs is increasing.1,5 Two different types of MRSA transmission are known. Endogenous MRSA comes from the patient’s own flora (including the nares), and exogenous MRSA comes from iatrogenic sources. Transmission may be possible from aerosolized bacteria from the nose of the patient released during surgery that contaminates
Many institutions have implemented the use of preoperative nasal methicillin-sensitive Staphylococcus aureus (MSSA)/MRSA screens for elective surgical procedures. These screens are performed using nasal swabs followed by laboratory testing to identify the organism. Positive nasal MRSA screens have resulted in perioperative decolonization protocols in an effort to reduce SSIs. However, nasal
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MRSA screens have false-negative results in 5-10% of cases.33-35 A recent study demonstrated that a history of a negative MRSA culture cannot be reliably used in place of a preoperative nasal MRSA screen to identify MRSA carriers because it misses over 80% of patients who tested positive for MRSA with preoperative nasal polymerase chain reaction.13 Patients who test positive for MSSA/MRSA are often decolonized preoperatively. Multiple techniques are available for the decolonization of nasal MSSA/ MRSA. These include oral antibiotics such as rifampin and doxycycline, intranasal topical agents such as mupirocin (2%) and povodone-iodine (5%), and skincleansing topical agents such as chlorhexidine (2%).58 Oral antibiotics have the most side effects, longest treatment protocol, highest resistance patterns, and worst penetration in the nares, making topical agents the first-line choice. Mupirocin is a natural antibiotic from Pseudomonas fluorescens and is effective in eradicating MSSA and MRSA from the nares.17-18,36 This method reaches decolonization rates of 83% with short-term nasal protocols.18 Mupirocin is a safe and well-tolerated method for nasal decolonization, with superficial irritation being the largest adverse reaction.22,36 Mupirocin is also believed to be safe in combination with chlorhexidine baths, which can eradicate MRSA and other bacteria from the skin.37 Povodone-iodine agents have also been used primarily with mupirocin-resistant strains.58 Decolonization of nasal MRSA with mupirocin and chlorhexidine baths results in a statistically significant decrease in MRSA and total S. aureus isolates in the clinical laboratory.38 “Treatment” of MRSA skin and wound infections is different than “decolonization” of asymptomatic nasal MSSA/MRSA carriers, and these terms should not be used interchangeably. The decolonization of MRSA in the nares varies by institution, making largescale meta-analyses difficult. Currently, nationwide guidelines do not routinely recommend protocols/ procedures for MRSA screening.39 No real agreement exists among institutions regarding the duration, frequency, and/or addition of chlorhexidine baths for the decolonization of MSSA or MRSA in the nares of carriers. The most common perioperative eradication method for positive nasal MRSA screens is mupirocin 2% topical ointment placed intranasally twice a day for 5 days plus chlorhexidine baths once every other day for the 5 days prior to surgical intervention. Patients undergoing elective surgical procedures may have follow-up appointments before surgery to confirm decolonization. This is routinely done in combination
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with perioperative IV cefazolin for MRSA-negative MSSA carriers and IV vancomycin for MRSA carriers. For hospital decolonization of positive nasal MRSA carriers with nasal application of mupirocin and chlorhexidine, body soaks for 5 days significantly decrease MRSA bacteremia and iatrogenic MRSA disease but have no impact on MSSA bacteremia.1,16 The above decolonization protocol with mupirocin and chlorhexidine results in a rate of MRSA SSI that decreases from 0.23% to 0.09% in all surgical patients and from 0.30% to 0% in TJA procedure patients.55 No current set of approved guidelines is available regarding empiric decolonization of nasal MSSA/MRSA versus screening followed by decolonization for preoperative elective orthopedic surgical cases.50 The latter approach for MRSA nasal carriage may prevent mupirocin resistance but does not appear to be cost-effective. Resistance is a common concern in using antibiotics. Concerns for mupirocin or chlorhexidine resistance with frequent use of these agents has raised questions about the empiric decolonization method.42-44 However, short courses used specifically for decolonization prior to operative intervention are not expected to cause widespread resistance.45 Mupirocin blocks protein synthesis in bacteria, and because this mechanism of action is distinct from other antibiotics, the opportunity for resistance is reduced. The decolonization of all patients, regardless of risk factors or likelihood of resistance, should be approached with caution. Risk factors include hospitalization within the past 24 months, current prolonged hospitalization, outpatient visit within the past 12 months, nursing home admission within the past 12 months, antibiotic exposure within the past 12 months, age over 65 years, co-morbid conditions, IV drug use, history of invasive procedures, and/ or close contact with a person who has any of the above risk factors.58 A study from the UK in 2009 recommended discontinuation of MRSA screening of all outpatient surgical patients due to poor use of resources, although the authors did note some utility in patients older than 65 years and with significant co-morbidities.51 Some studies show significant yearly economic gain with preoperative decolonization using mupirocin and chlorhexidine, reporting savings that approach $275,000 per year due to reduced SSIs.2,26 Is there a correlation between preoperative decolonization of MRSA in the nares and a reduction in postoperative MRSA SSIs? Many non-orthopedic surgical subspecialties have examined these data,
with varying results. Treatment with preoperative intranasal mupirocin and oral bactrim resulted in zero postoperative MRSA wound infections after dermatology outpatient surgery as compared to 0.3% without treatment.46 Preoperative treatment of cardiac surgery patients with mupirocin revealed no beneficial effects.47 A well-done systematic review and meta-analysis published in 2009 compared hospital wards applying rapid MRSA screening tests with proper decolonization to those that did not, and noted a significantly decreased risk for MRSA bloodstream infections but not for MRSA SSI.52 Decolonization studies in 2008/2009 in orthopedic surgery yielded mixed results. No reduction in orthopedic S. aureus SSIs was noted in two studies when using mupirocin, but articles published in the same years showed a reduction in orthopedic S. aureus SSIs.29,31,48-49 In 2010, orthopedic surgery patients were screened preoperatively for MRSA, and the authors concluded that hospitals and third-party payers would save money in most circumstances compared to not screening.53 Glassner et al. were unable to obtain definitive conclusions regarding MRSA screening for TJA patients in 2011, but stated that due to the significant cost and morbidity associated with postoperative MRSA infection, protocols for screening and decolonization should be considered for all elective or emergent surgical patients.54 The most recent data in 2011 showed that orthopedic surgical patients treated preoperatively with a combination of mupirocin and chlorhexidine had a decrease in TJA SSIs from 2.7% to 1.4%.26 This was replicated in a 2-year follow-up study that showed a decrease from 2.7% to 1.2%.2
CONCLUSION Currently, high-quality data on preoperative decolonization with mupirocin alone and/or in combination with chlorhexidine in non-elective orthopedic trauma patients are lacking. Due to the necessity of urgent fixation and/or stabilization of most orthopedic trauma patients, decolonization is not possible, making this type of research difficult. However, the most recent evidence does support the use of preoperative nasal MRSA decolonization in elective TJA.2 From an economic standpoint, the development of techniques to prevent postoperative SSIs is imperative, since hundreds of thousands of dollars could be saved by preventing revision surgeries.2,26 The majority of publications suggest some benefit of nasal MRSA decolonization prior to elective orthopedic surgery, although a need clearly exists for a large, multi-center study to clarify the
best treatment for preoperative orthopedic surgical patients who are nasal MSSA/MRSA carriers. This type of research will allow stratification of beneficial long-term data into models that may be used as the epicenter for new and improved national guidelines. The author has no relationship to disclose relating to the content of this article REFERENCES 1. Anderson DJ, Sexton DJ, Kanafani ZA, et al. Severe surgical site infection in community hospitals: epidemiology, key procedures, and the changing prevalence of methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol. 2007; 28(9):1047-53. 2. Rao N, Cannella BA, Crossett LS, et al. Preoperative screening/ decolonization for Staphylococcus aureus to prevent orthopaedic surgical site infection: prospective cohort study with 2-year follow-up. J Arthoplasty. 2011; 26(8):1501-1507. 3. Walley G, Orendi J, Bridgman S, Davis B, Ahmed E, Maffulli N. Methicillin resistant Staphylococcus aureus (MRSA) is not always caught on the orthopaedic ward. Acta Orthop Belg. 2009; 75(2):245-251. 4. Harbath S, Fankhauser C, Schrenzel J, et al. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA. 2008;299(10):1149-57. 5. Spellberg B, Guidos R, Gilbert D, Bradley J, Boucher HW, Scheld WM, Bartlett JG, Edwards Jr. J. The epidemic of antibiotic resistant infections: a call to action for the medical community from the Infectious Diseases Society of America. Clin Infect Dis. 2008; 46(2):155-164. 6. Casewell MW: The nose: an underestimated source of Staphylococcus aureus causing wound infection. J Hosp Infect. 1998;40(suppl B):3-11. 7. Kluytmans JA: Reduction in surgical site infections in major surgery by elimination of nasal carriage of Staphylococcus aureus. J Hosp Infect. 1998;40:S25-29. 8. Bozik KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010;468(1):45-51. 9. Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am. 2005;87(8):1746-51. 10. Hebert CK, Williams RE, Levy RS, Barrack RL. Cost of treating an infected total knee replacement. Clin Orthop Relat Res. 1996; 331: 140-145. 11. Lavernia C, Lee DJ, Hernandez VH. The increasing financial burden of knee revision surgery in the United States. Clin Orthop Relat Res. 2006; 446:221-226. 12. Kurtz SM, Ong KL, Lau E, et al. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res. 2010;468:52. 13. Strymish J, Branch-Elliman W, Itani KMF, Williams S, Gupta K. A clinical history of methicillin-resistant Staphylococcus aureus is a poor predictor of preoperative colonization status and postoperative infections. Infect Control Hosp Epidemiol. 2012;33(11):1113-1117. 14. Scudeller L, Leoncini O, Boni S et al. MRSA carriage: the relationship between community and healthcare setting: A study in an Italian hospital. J Hosp Infect. 2000;46(3):222-29. 15. Warshawsky B, Hussain Z, Gregson DB et al. Hospital and communitybased surveillance of methicillin-resistant Staphylococcus aureus: previous hospitalization is the major risk factor. Infect Control Hosp Epidemiol. 2000;21(11):724-727. 16. Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev. 1997;10(3):505-520. 17. Perl TM, Golub JE. New approaches to reduce Staphylococcus aureus Nosocomial infection rates: treating S. aureus nasal carriage. Annals Pharmacother. 1998;32:S7. 18. Wenzel RP, Perl TM. The significance of nasal carriage of Staphylococcus aureus and the incidence of postoperative wound infection. J Hospital Infec. 1995;31:13. 19. Perl TM, Cullen JJ, Wenzel RP, et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. New Engl J Med. 2002;346(24):1871-1877.
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20. Diekema D, Johannsson B, Herwaldt L, et al. Current practice in Staphylococcus aureus screening and decolonization. Infect Control Hosp Epidemiol. 2011;32(10):1042-1044.
40. Cimochowski GE, Harostock MD, Brown R, et al. Intranasal mupirocin reduces sternal wound infection after open heart surgery in diabetics and nondiabetics. Ann Thorac Surg. 2001;71(5):1572-1578.
21. Kluytmans JAJW, Mouton JW, Ijzerman EP, et al. Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery. J Infect Dis. 1995;171(1):216-219.
41. Wertheim HF, Vos MC, Ott A, Voss J, Kluytmans A, VandenbrouckeGrauls CM, Meester MH, van Keulen PH, Verbrugh HA. Mupirocin prophylaxis against nosocomial Staphylococcus aureus infections in nonsurgical patients: a randomized study. Ann Intern Med. 2004;140(6):419425.
22. Bode LG, Kluytmans JA, Wertheim HF, et al. Preventing surgical site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010; 362(1):9-17. 23. Gupta K, Strymish J, Abi-Haidar Y, Williams SA, Itani KM. Preoperative nasal methicillin-resistant Staphylococcus aureus status, surgical prophylaxis, and risk-adjusted postoperative outcomes in veterans. Infect Control Hosp Epidemiol. 2011;32(8):791-796. 24. Datta R, Huang SS. Risk of infection and death due to methicillin-resistant Staphylococcus aureus in long-term carriers. Clin Infect Dis. 2008;47(2):176181. 25. Huang SS, Platt R. Risk of methicillin-resistant Staphylococcus aureus infection after previous infection or colonization. Clin Infect Dis. 2003;36:281285. 26. Rao N, Cannella B, Crossett LS, et al. A preoperative decolonization protocol for Staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res. 2008; 466(6):1343-8. 27. Perl TM. Prevention of Staphylococcus aureus infections among surgical patients: beyond traditional perioperative prophylaxis. Surgery. 2003;134 (5 Suppl):S10. 28. Kim DH, Spencer M, Davidson SM, et al. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg. 2010;92(9):1820-6. 29. Hacek DM, Robb WJ, Paule SM, et al. Staphylococcus aureus nasal decolonization in joint replacement surgery reduces infection. Clin Orthop Relat Res. 2008;466(8):1349-1355. 30. Price CS, Williams A, Philips G, Dayton M, Smith W, Morgan S. Staphylococcus aureus nasal colonization in preoperative orthopaedic outpatients. Clin Orthop Relat Res. 2008; 466(11):2842-2847. 31. Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, et al. Surgical site infections in orthopaedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis. 2002;35(4):353-8. 32. Kalmeijer MD, van Niewwland-Bollen E, Bogaers-Hofman D, et al. Nasal carriage of Staphylococcus aureus is a major risk factor for surgicalsite infections in orthopaedic surgery. Infect Control Hosp Epidemiol. 2000;21(5):319-23. 33. Wolk DM, Picton E, Johnson D, et al. Multicenter evaluation of the Cepheid Xpert methicillin-resistant Staphylococcus aureus (MRSA) test as a rapid screening method for detection of MRSA in nares. J Clin Microbiol. 2009;47(3):758-764. 34. De San N, Denis O, Gasasira MF, De Mendonca R, Nonhoff C, Struelens MJ. Controlled evaluation of the IDI-MRSA assay for detection of colonization by methicillin-resistant Staphylococcus aureus in diverse mucocutaneous specimens. J Clin Microbiol. 2007;45(4):1098-1101. 35. Olchanski N, Mathews C, Fusfeld L, Jarvis W. Assessment of the influence of test characteristics on the clinical and cost impacts of methicillin-resistant Staphylococcus aureus screening programs in US hospitals. Infect Control Hosp Epidemiol. 2011;32(3):250-257.
42. Leski TA, Gniadkowski M, Skoczynska A, et al. Outbreak of mupirocinresistant staphylococci in a hospital in Warsaw, Poland, due to plasmid transmission and clonal spread of several strains. J Clin Microbiol. 1999;37(9):2781-8. 43. Deshpande LM, Fix AM, Pfaller MA, et al. Emerging elevated mupirocin resistance rates among staphylococcal isolates in the SENTRY Antimicrobial Surveillance Program (2000): correlations of results from disk diffusion, Etest and reference dilution methods. Diagn Microbiol Infect Dis. 2002;42(4):283-90. 44. Batra R, Cooper BS, Whiteley C, et al. Efficacy and limitation of a chlorhexidine-based decolonization strategy in preventing transmission of methicillin-resistant Staphylococcus aureus in an intensive care unit. Clin Infect Dis. 2010;50(2):210-7. 45. Ammerlaan HS, Kluytmans JA, Wertheim HF, et al. Eradication of methicillin-resistant Staphylococcus aureus carriage: a systematic review. Clin Infect Dis. 2009; 48(7):922-30. 46. Cordova KB, Grenier N, Chang KH, Dufresne R Jr. Preoperative methicillan-resistant Staphylococcus aureus screening in Mohs surgery appears to decrease postoperative infections. Dermatol Surg. 2010;36(10):15371540. 47. Konvalinka A, Errett L, Fong IW. Impact of treating Staphylococcus aureus nasal carriers on wound infections in cardiac surgery. J Hosp Infect. 2006;64(2):162-168. 48. Gernaat-van der Sluis AJ, Hoogenboomm-Verdegaal AM, Edixhoven PJ, et al. Prophylactic mupirocin could reduce orthopedic wound infections. 1,044 patients treated with mupirocin compared with 1,260 historical controls. Acta Orthopaedica Scand. 1998;69(4):412-4. 49. Nixon M, Jackson B, Varghese P, et al. Methicillin resistant Staphylococcus aureus on orthopaedic wards: incidence, spread, mortality, cost and control. J Bone Joint Surg Br. 2006;88(6):812-7. 50. Courville XF, Tomek IM, Kirkland KB, Birhle M, Kantor SR, Finlayson SRG. Cost-effectiveness of preoperative nasal mupirocin treatment in preventing surgical site infection in patients undergoing total hip and knee arthroplasty: a cost-effectivenss analysis. Infect Control Hosp Epidemiol. 2012;33(2):152-159. 51. Enoch DA, Carter NM, Karas JA. MRSA screening of elective surgery daycase patients. J Hosp Infect. 2010;74(3):291-292. 52. Tacconelli E, De Angelis G, de Waure C, Cataldo MA, La Torre G, Cauda R. Rapid screening tests for methicillin-resistant Staphylococcus aureus at hospital admission: systematic review and meta-analysis. Lancet Infect Dis. 2009;9(9):546-554. 53. Lee BY, Wiringa AE, Bailey RR, Goyal V, Tsui B, Lewis GJ, Muder RR, Harrison LM. The economic effect of screening orthopedic surgery patients preoperatively for methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol. 2010;31(11): 1130-1138. 54. Glassner PJ, Slover JD, Bosco JA, Zuckerman JD. Blood, bugs, and motion: What do we really know in regard to total joint arthroplasty? Bull NYU Hosp Jt Dis. 2011;69(1):73-80.
36. Ammerlaan HS, Kluytmans JA, Wertheim HF, et al. Eradication of methicillin-resistant Staphylococcus aureus carriage: a systematic review. Clin Infect Dis. 2009;48(7):922-30.
55. Pofahl WE, Goettler CE, Ramsey KM, Cochran MK, Nobles DL, Rotondo MF. Active surveillance of MRSA and eradication of the carrier state decreases surgical-site infections caused by MRSA. J Am Coll Surg. 2009;208(5):981-986.
37. Kaiser AB, Kernodle DS, Barg NL, et al. Influence of preoperative showers on staphylococcal skin colonization: a comparative trial of antiseptic skin cleansers. Annals Thoracic Surg. 1988;45(1):35-8.
56. Chalfi ne A, Kitzis MD, Bezie Y, Benali A, Perniceni L, Nguyen JC, Dumay MF,Gonot J, Rejasse G, Goldstein F, Carlet J, Misset B: Ten-year decrease of acquired methicillin-resistant Staphylococcus aureus (MRSA) bacteremia at a single institution: the result of a multifaceted program combining cross transmission prevention and antimicrobial stewardship. Antimicrob Resist Infect Control. 2012;1(18):1-7.
38. Hacek DM, Paule SM, Thomson RB Jr, Robicsek A, Peterson LR. Implementation of a universal admission surveillance and decolonization program for methicillin- resistant Staphylococcus aureus (MRSA) reduces the number of MRSA and total number of S. aureus isolates reported by the clinical laboratory. J Clin Microbiol. 2009;47(11):3749-3752. 39. Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(suppl 1):S51-S61.
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57. Landelle C, Pagani L, Harbarth S. Is patient isolation the single most important measure to prevent the spread of multidrug-resistant pathogens? Virulence. 2013;4(2):0-1. 58. Larkin SA, Murphy BS. Preoperative decolonization of methicillin-resistant Staphylococcus aureus. Orthopedics. 2008;31(1):37-41.
PA Owned and Operated Brant Bell, PA-C Seven Springs Orthopaedics & Sports Medicine, Brentwood, TN
The fall season brings about several events that can be summed up in one simple word: change. As the warmth of summer begins to ebb and the coolness of fall begins to dominate the air, change is inevitable. The flowers wither; the pace of the growing grass slows and it fades to brown; and best of all, the leaves begin to morph into a sea of vibrant colors that amaze and bewilder at the same time. It would be difficult to name a more beautiful season of change than the fall, especially in Middle Tennessee, where I live and work. Change. This word causes a wave of emotions in all of us. We have all experienced change. Benjamin Franklin said, “The only things certain in life are death and taxes.” One could argue the quote should read, “The only things certain in life are death, taxes, and change.” Change can cause you to cringe in fear about what is happening around you, or can breathe life into a stale environment. In my career as a physician assistant, I have witnessed both ends of the spectrum and experienced highs and lows. In the fall of 2005, I was practicing orthopedics in a small practice with two surgeons and two PAs, including myself. My PA partner and I would treat approximately 80 of the 100 patients that came through the clinic doors each day. It was, and still is, a wonderful place to practice orthopedic medicine. The setting was pristine: a brand new office space located in the most coveted part of town. The two surgeons treated me well and taught me a great deal about orthopedics; our relationship grew and developed trust and respect that any PA would covet. I was not interested in change. I was content – or so I thought. As the grind of each day wore on, I became somewhat bitter about the situation. Bitterness was admittedly not the healthiest way to respond to my situation, but I’m trying to be truthful about the feelings I experienced and how I chose to deal with them. Rather than bury the bitterness and allow it to fester, I decided to do something about it. I was fully aware of the revenue I was generating for the clinic by personally treating
Brant Bell, PA-C
Stu Jones, PA-C approximately 40 patients per day. My PA partner and I approached the surgeons to ask for a productivity bonus based on the revenue we generated for the clinic. The request was not well received. We were told that we had “topped out” in terms of earning potential, and “if you can find something better to do, go do it.” Those words reverberated in our minds for weeks as we decided how to respond. We experienced a variety of emotions as we processed the surgeons’ response.
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As my PA partner and I talked about it each day, we came to the conclusion that something had to change. There’s that word again: change. How do you change a situation if you do not know what the options are for change? As we pondered our possible moves, we contacted the attorney who represents the Tennessee Academy of Physician Assistants (TAPA) to explore options. What we found breathed life into dreams we had been discussing. We found that Tennessee is a very favorable state for PA-owned practices. Several discussions by phone and email with the TAPA attorney ensued, and it was increasingly clear that our dreams could become reality. We leaped into establishing Seven Springs Orthopaedics and Sports Medicine, knowing that a PA-owned specialty clinic had never existed. Being the first at something is very exciting, but also brings many challenges. Funding such a venture is one of the largest obstacles to overcome. We created a business plan and met with three executives at a local bank to make our presentation. The bank agreed to become our lender for the project. One of the fastest ways to fail in business is to be underfunded, so we secured a revolving line of credit that would allow us to continue to fund the venture, knowing that it takes time to grow a medical clinic to a selfsustaining revenue generator. Our next big hurdle was deciding where to place the clinic. Our non-compete clause meant we could not be in the same county as our previous employer. We found a new medical office building in the next county, signed a 10-year lease, and built out our clinic space as the building development was completed. We were the only tenants in the building for the first year, which certainly did not help us grow any faster.
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The next puzzle piece was partnering with an orthopedic surgeon or group of surgeons who would support our concept. We felt strongly that we had a story worth telling and an idea that would lead to a friendly and natural referral source for new surgery referrals. Our experience told us that most surgeons are happiest in the operating suite and prefer to let a PA handle office visits. We were very fortunate to partner with Premier Orthopedics and Sports Medicine, the finest orthopedic group in the Middle Tennessee area, giving us access to a group of 28 surgeons in various orthopedic subspecialties to whom we refer patients in need of surgery. Our attorneys negotiated an affiliation agreement between our organizations and we settled on a rotation of four orthopedic surgeons coming through our clinic each week to meet patients for surgical referrals, follow-up on post-surgical patients, handle Medicare patient referrals, and meet the rare patient who only wants to be seen by a medical doctor. In August 2006, Seven Springs Orthopaedics and Sports Medicine was established and we opened our doors for service. On day one, not a single patient darkened our doors for treatment. Talk about nerves! On day two, we treated three patients. The story continues with slow, steady growth from that date forward. In February 2009, we opened our second location approximately 24 miles away, and both locations are now thriving with patient flow and an ever-growing referral network. We have had over 20,000 new patients in just over 6 years. We feel thoroughly blessed and know that we must continuously work harder than other orthopedic groups to maintain a high level of service to the community and our referral network to keep everyone satisfied. We feel that we must prove ourselves daily by offering better quality and speed of service than any of our competitors. Every Monday through Friday, we offer same-day appointments, with the office notes from each visit faxed to the referring physician the very next day so communication is fast and accurate. A venture of this magnitude is not without challenges. We often feel that our challenges are moving targets and we have to be nimble to adjust our tactics successfully. Since a PA-owned clinic had never been done before, we had no standard to which we could compare ourselves. We were
setting the standard, which can be challenging in and of itself. Every day, we wear many hats. First, we are PAs and have to meet the high standards of our profession to practice medicine with proper supervision. Our surgeons review our office notes and x-rays each day. We made an extra investment in digital x-ray capabilities so that an offsite surgeon can review x-rays immediately to make critical decisions regarding patient care. We meet regularly with our surgeons to ensure that we are meeting their expectations for patient care. These meetings have developed a wonderful working relationship with reciprocating respect and trust. What does the future hold? Without a doubt, more change. Some of the changes will be out of our control, such as the effects of the Affordable Care Act, and we must maneuver to meet the requirements of those new regulations. Other changes we can control and those are very exciting to plan and implement. We want to continue to improve our current clinics to become more efficient and treat more patients in the years
ahead. We want to hire more PAs to join the Seven Springs Orthopaedics and Sports Medicine family. We have long-term plans to add more clinics and to work with more surgeons. We want to move into a consulting role and help other PAs navigate the challenges of becoming clinic owners and operators. The possible directions of this venture are endless and thrilling to contemplate. Just as the seasons change and the days on the calendar tick by, our lives and careers change and can become something very different than we intended. When I enrolled in graduate school to become a PA, I never imagined owning and operating my own orthopedic clinics. I hope this article sparks an interest in exploring the possibilities of change in your career path, which may afford you the same opportunities to own a clinic in the years ahead. It is a very difficult mountain to climb, but when you reach the peak and look back at the path you conquered and all you accomplished, as well as consider what possibilities lie ahead, it is well worth the risks and efforts required. The author has no relationship to disclose relating to the content of this article
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Salary surveys Job listings CME announcements Clinical “pearls” Test-Your-Knowledge Q&As More articles focused on PAs in orthopedics – us! JOPA 35
Nonoperative Treatment of Knee Osteoarthritis It is common to see patients in the clinic complaining of knee pain, many of whom have osteoarthritis (OA). Most patients with knee OA can initially be treated successfully with nonoperative modalities, although eventually, surgical treatment may be necessary to resolve symptoms. Medicare requires increasingly stringent documentation of nonoperative treatment failures prior to approving payment for arthroplasty procedures. It is no longer sufficient to dictate that a patient “failed nonoperative treatment for knee OA and is ready to proceed with total knee arthroplasty.� Hospital records must indicate the duration, specific types, and outcomes of nonoperative treatments that have been performed. Specific functional limitations and activity modifications should be documented in the hospital chart. A minimum of 3 months of nonoperative management needs to be documented in the patient’s history and physical. What nonoperative treatments are most beneficial to patients? In 2009, the American Academy of Orthopaedic Surgeons (AAOS) published clinical practice guidelines, based on the available literature, that address the effectiveness of various knee OA treatments.1 These guidelines provide recommendations for or against interventions based on evidence available for each treatment. Evidence for each intervention is graded on different levels: Level 1 has good evidence of effectiveness, Levels 2 and 3 have fair evidence, and Levels 4 and 5 show poor-quality evidence. An inconclusive recommendation is made when insufficient or conflicting evidence is available. Recommendations for each intervention are given a final grade: A for recommended, B for suggested, C for optional, and Inconclusive for neither recommended nor not recommended. Other guidelines have been published by the Osteoarthritis Research Society International2-3 and the American College of Rheumatology4. This article summarizes current recommendations and provides scientific rationale for the use of nonoperative treatments.
WEIGHT LOSS The average American weighs more today than 10 years ago. According to data from the Centers for Disease Control, over one-third of adults in the United States are obese. In 2004, only nine states reported that more than 25% of their population was obese (body mass index >30); in 2010, this number rose to 35 states.5 Obese patients are more likely to undergo joint replacement at a younger age.6 Does excessive weight make an already arthritic joint more painful or does it directly damage the joint? The answer is probably both. Massive weight loss after bariatric surgery has been shown to significantly reduce pain associated with osteoarthritis.7 In fact, some studies indicate a possible cellular cause of cartilage breakdown associated with OA in obese patients.8-9 Although weight loss can reduce symptoms, it will not repair the damage to articular cartilage. The AAOS clinical guidelines recommend that patients with osteoarthritis and a body mass index greater than 25 are encouraged to lose a minimum of 5% of their body weight and to maintain the weight loss through diet and exercise (Level I evidence, Grade A recommendation).1 This recommendation is based on randomized controlled studies that demonstrate a reduction in arthritic symptoms with weight loss.10
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Figure 1. Non weight-bearing AP view
Figure 2. Weight-bearing AP view
Figures 1 and 2 illustrate the importance of obtaining weight-bearing films to accurately depict joint space narrowing and OA severity. Figure 2 shows an increase in medial joint space narrowing and varus deformity with weight-bearing.
PHYSICAL THERAPY A structured exercise program or physical therapy is commonly recommended for patients with knee OA. Patients often question whether this is useful and may complain about the high cost of their co-payment. Certainly, patients who demonstrate weakness of the quadriceps and hamstrings, gait abnormalities, and/or poor balance will benefit from a strengthening program. A structured physical therapy program encourages compliance with exercises and ensures that they are performed safely. Periarticular muscle strengthening and stretching helps maintain and improve joint mobility and increases joint stability. The AAOS clinical guidelines recommend low impact aerobic exercise (Level I evidence, Grade A recommendation). The benefits of quadriceps strengthening (Level II evidence, Grade B recommendation) and range of motion exercises (Grade C recommendation) are less evident.1
ASSISTIVE DEVICES Many patients with arthritis do not wish to use a cane or a walker, as they do not want to appear disabled. Elderly patients often consider not using assistive devices a point of pride. However, if used correctly, a cane or a crutch in the opposite hand as the affected joint will reduce joint reactive forces.11 A walker can also improve balance and may be easier for some patients to use.
BRACING Many different types of braces can be used for OA, such as a simple wrap, tape placed on the knee, and metal-hinged custom-fitted braces. Orthotics can also be placed in the shoe to modify gait patterns. Patients often like braces because they feel that the brace gives them support. In fact, many patients report pain relief and improved function with bracing.12 The effectiveness of braces, however, is not universally agreed upon and they are often expensive. Neoprene braces are thought to provide warmth and support to muscles; however, a recent study found that vastus medialis muscle activation during squatting decreased while using a brace.13 Additionally, if patients find braces uncomfortable or ineffective, they will stop using them. For example, one study of patients prescribed medial unloader braces for OA found that after 2 years,
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only 25% of patients were still using the brace.14 The AAOS clinical guidelines also show modest support for patellar taping (Level II evidence, Grade B recommendation), but did not feel that sufficient evidence existed to give support for or against the use of unloader style braces. Well designed, randomized studies are needed to determine the effectiveness of bracing. Finally, strong recommendations against the use of lateral heal wedges were made because of limited data showing effectiveness.1
MEDICATIONS Commonly prescribed medications for knee OA include acetaminophen, oral and topical non steroidal anti-inflammatories (NSAIDs), and COX-2 selective inhibitors. A Cochrane review of randomized controlled studies found that both acetaminophen and NSAIDS significantly improve pain relief in knee arthritis compared to placebo. Acetaminophen has a lower associated risk of complications,whereasNSAIDS appear to be more effective for pain relief.15 The U.S. Food and Drug Administration (FDA) recently lowered the recommended maximum dose of acetaminophen to 3g per day to reduce the risk of accidental overdose and subsequent liver damage. NSAIDS are associated with risks of gastrointestinal (GI) bleeding and kidney damage, and long term use may have negative effects on the cardiovascular system. GI bleeds remain the most common side effect of NSAIDS. Risk factors for GI bleeds in patients using NSAIDs include an age over 60 years, alcohol or tobacco use, a history of peptic ulcer disease or prior GI bleeds, and concomitant use of oral steroids or anticoagulants. Combination treatment with proton pump inhibitors (PPIs) and COX-2 inhibitors provides the best protection against GI bleeding in high risk patients.16 Topical NSAIDS have also been shown, in some randomized controlled studies, to be as effective as oral NSAIDs and they may have a lower associated risk of GI side effects.17 Other topical agents such as methylsalicylates and capsaicin cream may be beneficial for those who cannot tolerate, or choose to avoid, systemic therapies. AAOS clinical guidelines support the use of acetaminophen and NSAIDs to treat knee OA (Level II evidence, grade B recommendation). For patients greater than 60 years of age or at increased risk of GI bleeding, COX-2 inhibitors, PPIs, and topical NSAIDs are recommended as well.1 Although some studies have shown glucosamine and chondroitin sulfate to be effective for treating arthritis pain, AAOS clinical guidelines strongly recommended against their use (Level I evidence, grade A recommendation).1 Tramadol may be considered in patients with impaired renal function or who have failed prior oral therapies. For patients with severe pain, more potent opioids may be used with caution to prevent tolerance, dependence, and associated adverse effects.
STEROID INJECTIONS Corticosteroid injections into the knee joint are a common treatment for knee OA. Pain relief is the greatest during the first 4 weeks following the injection; however, this is accompanied by minimal change in functional status.18 The usual recommendation is to perform injections no more frequently than every 3 months. In patients with OA, steroid injections every 3 months compared to a placebo for 2 years were found to be safe, provide pain relief, and were not associated with progression of OA.19 Basic science research and clinical reports indicate that steroids may damage chondrocytes, although it is unclear if this is related to the steroid itself or to the local analgesic agents that are often administered concurrently.20 Therefore, intra-articular steroid injections should be used cautiously or not at all in patients with knee pain but without significant arthritic changes. AAOS clinical guidelines recommend the use of corticosteroid injections for knee OA (Level II evidence, grade B recommendation).1
VISCOSUPPLEMENTATION Viscosupplementation with hyaluronic acid (HA) is an FDA approved medical device used for treating knee OA. A healthy knee contains 2 ml of synovial fluid, with an HA level of 2.5 to 4 mg/ml. The concentration and molecular size of HA is decreased in arthritic knee joints, resulting in lower dynamic viscous and elastic properties of the synovial fluid. Viscosupplementation was developed to preserve the lubricating and shock absorbing properties of healthy synovial fluid, properties that are essential for maintaining the integrity of
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articular surfaces. Intra-articular administration of HA has also been found to reduce inflammatory mediators, diminish pain signals, and it might stimulate synovial fibroblasts to produce HA.21 The efficacy of HA injections have been evaluated in several studies. A large systematic review published in 2006 found beneficial effects in pain, function, and global assessment, especially during the 5- to 13-week post-injection period.22 A meta-analysis published in 2004 found significant improvements in pain and functional outcomes in the treatment of patients with knee OA. However, patients with advanced radiographic osteoarthritic changes were less likely to benefit from HA injections.23 A number of different HA products exist today, many of which differ in molecular weight, dosage per injection, and recommended number of injections. Repeated courses are generally effective and well tolerated; efficacy is typically determined by the severity and progression of OA. One meta-analysis suggests that pain relief following viscosupplementation may be longer lasting than with corticosteroids.24 Current research is exploring the chondro-protective properties of HA and the potential analgesic properties for acute chondral injuries and post-arthroscopy pain. AAOS clinical guidelines found data on viscosupplementation to be inconclusive due to study methodology and the manner in which the studies were pooled for the meta-analysis. They were therefore unable to make a recommendation for or against the use of viscosupplementation.1
CONCLUSIONS There are many nonoperative treatment options for patients with OA, most of which provide symptomatic relief. However, none of these treatments prevent progression of OA. Although some patients get long-lasting relief with nonoperative measures, many will have progressive limitations to their ability to ambulate and perform activities of daily living and will require surgical treatment. Additionally, it is important to document all nonoperative interventions before proceeding with joint replacement surgery. Dr. Hogan is a consultant for Cadence Pharmaceuticals and Ferring Pharmaceuticals. References 1. Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (nonarthroplasty).J Am Acad Orthop Surg. 2009;17(9):591-600. 2. Zhang W, Moskowitz RW, Nuki G, Abramson S, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines.Osteoarthritis Cartilage. 2008;16(2):137-62 3. Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 2010;18(4):476-99. 4. Hochberg MC, Altman RD, April KT, Benkhalti M, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012;64(4):465-74. 5. Centers for Disease Control and Prevention. Adult Obesity Facts. http:// www.cdc.gov/obesity/data/adult.html. 2/26/13. 6. Changulani M, Kalairajah Y, Peel T, et al. The relationship between obesity and the age at which hip and knee replacement is undertaken. J Bone Joint Surg Br. 2008;90(3):360-3. 7. Edwards C, Rogers A, Lynch S, et al. The effects of bariatric surgery weight loss on knee pain in patients with osteoarthritis of the knee. Arthritis. 2012;2012:504189. 8. Rojas-Rodríguez J, Escobar-Linares LE, Garcia-Carrasco M, et al. The relationship between the metabolic syndrome and energy-utilization deficit in the pathogenesis of obesity-induced osteoarthritis. Med Hypotheses. 2007;69(4):860-8. 9. Hui W, Litherland GJ, Elias MS, et al. Leptin produced by joint white adipose tissue induces cartilage degradation via upregulation and activation of matrix metalloproteinases. Ann Rheum Dis. 2012;71(3):455-62. 10. Christensen R, Bartels EM, Astrup A, et al. Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta-analysis. Ann Rheum Dis. 2007;66(4):433-9. 11. Simic M, Bennell KL, Hunt MA et al. Contralateral cane use and knee joint load in people with medial knee osteoarthritis: the effect of varying body weight support. Osteoarthritis Cartilage. 2011;19(11):1330-7. 12. Briggs KK, Matheny LM, Steadman JR. Improvement in quality of life with use of an unloader knee brace in active patients with OA: a prospective
cohort study. Knee Surg. 2012;25(5):417-21. 13. Choi EH, Kim KK, Jun AY et al. Effects of the off-loading brace on the activation of femoral muscles -a preliminary study. Ann Rehabil Med. 2011;35(6):887-96. 14. Squyer E, Stamper DL, Hamilton DT, et al. Unloader Knee Braces for Osteoarthritis: Do Patients Actually Wear Them? Clin Orthop Relat Res. 2013 Feb 2. 15. Towheed TE, Maxwell L, Judd MG, et al. Acetaminophen for osteoarthritis. Cochrane Data- base Syst Rev. 2006;Jan 25;(1). 16. Chan FK, Wong VW, Suen BY, et al. Combination of a cyclooxygenase-2 inhibitor and a proton- pump inhibitor for prevention of recurrent ulcer bleeding in patients at very high risk: a double-blind, randomized trial. Lancet. 2007;369(9573):1621-6. 17. Derry S, Moore RA, Rabbie R. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2012 Sep 12;9. 18. Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006 Apr 19;(2) 19. Raynauld JP, Buckland-Wright C, Ward R, et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2003;48(2):370-7. 20. Syed HM, Green L, Bianski B, et al. Bupivacaine and triamcinolone may be toxic to human chondrocytes: a pilot study. Clin Orthop Relat Res. 2011;469(10):2941-7. 21. Esdaile JM, Watterson JR. Viscosupplementation: Therapeutic Mechanisms and Clinical Potential in Osteoarthritis of the Knee. J Am Acad Orthop Surg. 2000;8(5):277-84. 22. Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;Apr 19;(2). 23. Chen-Ti Wang; Jinn Lin; Chee-Jen Chang; Yu-Tsan Lin; Sheng-Mou Hou. Therapeutic effects of hyaluronic acid on osteoarthritis of the knee. A meta-analysis of randomized controlled trials. J Bone Joint Surg Am. 2004;86A(3):538-45. 24. Bannuru RR, Natov NS, Obadan et al. Therapeutic trajectory of hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: a systematic review and meta-analysis. Arthritis Care Res. 2009;61:1704–11.
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Physical Therapy Corner The Graston® Technique and Treatment of Soft Tissue Dysfunction • Plantar fasciitis • Cervical pain • Epicondylitis • Muscle strains
Karin Biskovich, MPT Apple Therapy Services, Amherst, NH
Certified Graston® Provider I treated a patient with Achilles tendonosis 5 years ago. He was referred to me because he had an injury to his Achilles tendon that was non-surgical and limited his ability to walk with a normal gait and participate in his recreational hobbies. After a few sessions of trying aggressive cross-friction work to the tendon, the patient reported improvement and pain reduction with walking and tendon stretch. However, I had difficulty performing the treatment because my hands fatigued quickly. During my care of this patient, I attended a continuing education conference and learned about instrument-assisted soft tissue mobilization (IASTM) techniques. Shortly thereafter, I attended a training session for the Graston® Technique, one form of IASTM, and purchased the required instruments. I quickly observed the benefits of adding this technique to my treatment plans, and I now find it effective for the treatment of the following soft tissue dysfunctions: • ITB syndrome
• Achilles tendonitis • Patellofemoral syndrome • Patella tendonitis • Painful scars
The technique uses six stainless steel instruments with concave/convex shapes to match the different parts of the body. Using the curvilinear edges of the metal instruments, I am able to detect fascial restrictions that inhibit the lengthening of the muscle and limit recovery. The Graston Technique tools act as focused extensions of my hands. Performing the Graston Technique in conjunction with a specific stretching, selfmyofascial mobilization, and strengthening program helps my patients reduce their pain level and often continue their activities as well. In particular, I am able to use the Graston Technique to treat patients in positions of symptom provocation and with movement. I have been a therapist in an outpatient orthopedic setting for 10 years and have used the Graston Technique for 3 years. I believe that the Graston Technique allows me to offer patients a more effective tool for their care that allows them to return to their activities more quickly. The author has no relationships to disclose relating to the content of this article.
• Low back pain
Clinical Pearl A transcutaneous electrical nerve stimulation (TENS) unit uses electrodes to deliver a light current to the skin and us underlying tissues. Electrodes send stimulating pulses to un help prevent pain signals from reaching the brain. he
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Sideline Diagnosis and Management of Sports-Related Concussions Tyler Kimbar, AT-C Performance Rehab, Nashua, NH
Concussions are among the most difficult sportsrelated injuries to diagnose and manage. No imaging techniques that can accurately determine whether a person has a concussion are currently available, making a diagnosis almost entirely subjective1. Each athlete will have unique symptoms and react differently to each concussion. Misguided by a fear of missing games, many athletes and some coaches try to hide symptoms so that the athlete can continue playing. If an athlete has had a previous concussion, the severity of a new concussion is instantly increased. With more research published every day regarding the shortand long-term effects of concussions, it is essential to recognize key signs and symptoms and know what to do when someone has a concussion. Education and a fast response time are vital for sideline concussion management. The incidence of concussions is highest in American football, with approximately 250,000 concussions and an average of eight associated deaths in teen athletes annually2. Concussions are caused by linear and/or rotational forces that are sent through the brain, either by a traumatic or nontraumatic injury3. Immediately following an injury, ionic shifts occur at the cellular level, leading to acute and subacute changes. Acutely, stretching of nerve fibers results in a cellular shift of potassium and calcium ions. Sodium/potassium pumps work harder to restore membrane potential, resulting in an increased glucose demand. This increased energy demand is accompanied by a decrease in cerebral blood flow, which creates an energy crisis and diminished brain function. Subacutely, persistently elevated levels of intracellular calcium ions impair neural connectivity and can lead to cell death4. The first part of sideline concussion management is making sure the cervical spine is clear of any injuries. Any palpable pain over the cervical spine with numbness or tingling in the extremities, requires cervical stabilization and transportation by emergency medical services to a hospital. In case of
a suspected cervical injury, it is imperative to leave the player’s helmet on, keeping the cervical spine in neutral alignment to limit cervical motion, and only remove the face mask to maintain a proper airway. The helmet should only be removed if cardiovascular or respiratory distress is present or stabilization cannot be maintained due to poor fit. If the helmet is dislodged during injury, placing a folded towel under the player’s head can help maintain neutral alignment of the cervical spine5. After the cervical spine is cleared, evaluation of current symptoms is necessary. Common concussion symptoms may include but are not limited to headache, dizziness, nausea, tinnitus, sensitivity to light or sound, delayed responses, a feeling of fogginess, slurred speech, nystagmus, balance problems, and drowsiness6. Loss of consciousness (LOC) is not required for an injury to be considered a concussion, and unless the duration is greater than 1 minute, LOC is not an indicator of concussion severity1. A common sideline “pocket” test that can be used during a game or practice is the Sport Concussion Assessment Tool 2 (SCAT2), which includes a standard list of questions for checking symptoms and memory function and an objective balance test1. Evaluations and questioning should happen every 5 minutes to ensure that symptoms are not worsening and the athlete is not deteriorating. If any symptoms worsen, the athlete must be immediately transferred to a hospital1. Observe and note how the athlete answers questions and try to determine if
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responses are delayed while checking short- and longterm memory and the ability to focus. More severe symptoms like retrograde and anterograde amnesia lasting more than 15 minutes, anisicoria, excessive vomiting, LOC, deterioration of symptoms, trouble staying lucid, and any blood or cerebrospinal fluid leaking from the ear canal may indicate a potentially life-threatening condition. Anisocoria is a possible indicator of a subdural or epidural hematoma, which if left untreated could lead to death1. These symptoms may not be apparent for hours or days after the initial injury and should not be missed during a thorough examination. Cranial nerve assessments can be used to determine if any deficits due to increased intracranial pressure from a concussion are present. Pupillary reaction, balance, sensation, and motor function can all be tested during a cranial nerve assessment. Testing dermatomes and myotomes may also be helpful in finding neurological deficits. When taking the athlete’s history, previous and recent concussions must be carefully considered. Second-impact syndrome (SIS) happens when an athlete sustains a second concussion before symptoms of a prior concussion have subsided. SIS is more common in teenagers and is characterized by rapid swelling of the brain that causes sudden and severe loss of neurological function. Nearly 50% of SIS cases lead to death, and 100% result in brain damage2. Thus, recognizing concussion symptoms and preventing an injured athlete from returning too early are crucial. Numerous grading scales for concussions have been reported, but none are widely accepted. However, most scales do agree on the use of LOC and amnesia as determining factors for grading. The American Academy of Neurology uses grades 1-3 based on LOC and symptoms of confusion. Mild or grade 1 is associated with no LOC and confusion lasting less than 15 minutes, moderate or grade 2 involves no LOC with confusion lasting greater than 15 minutes, and with a severe or grade 3 concussion, LOC does occur. The Cantu Grading Scale has a similar 1-3, or mild, moderate, and severe, grading system. Grade 1 is associated with no LOC and postinjury amnesia less than 30 minutes, grade 2 involves LOC for less than 5 minutes with amnesia lasting less than 24 hours, and grade 3 involves LOC greater than 5 minutes with post-traumatic amnesia lasting over 24 hours. Although no grading scales are currently
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widely accepted, LOC greater than 1 minute and posttraumatic amnesia lasting longer than 30 minutes are understood to be signs of more severe concussions5. Athletes will sometimes try to withhold, hide, or disguise symptoms so they can continue to play, making a thorough exam critical. Continually checking symptoms until the athlete is in stable condition is vital. Athletes who experience concussion symptoms should not return to play on the same day. A full neuropsychological exam and a symptom-free, progressive cardio workout should be required before returning to sports. Education plays an important role in sideline management of concussions. It is essential for the health care provider to remain accessible to the injured player and the injured player’s family until they seek further medical attention. Providing written and oral instructions to an injured athlete can increase compliance by 55% following a concussion3. Diagnosing and managing concussions from the sidelines are difficult tasks that cannot be taken lightly. Research studies concerning concussion diagnosis, management, and long-term effects continue to be published. Many leaders in concussion research gathered at the fourth International Conference on Concussion in Sport in November, 2012 in Zurich, Switzerland, which was organized with assistance from sports organizations including the International Olympic Committee, International Ice Hockey Federation, Fédération Internationale de Football Association, International Rugby Board, and Fédération Equestre Internationale. New findings from this conference will be published in the early months of 2013. The author has no relationships to disclose relating to the content of this article.
References 1. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus statement on concussion in sport-the Third International Conference on Concussion in Sport held in Zurich, November 2008. Phys Sportsmed. 2009;37(2):141-159. 2. Durand P, & Adamson GJ. On-the-field management of athletic head injuries. J Am Acad Orthop Surg. 2004;12(3):191-195. 3. Scorza KA, Raleigh MF, O’Connor FG. Current concepts in concussion: evaluation and management. Am Fam Physician. 20112;85(2):123-132. 4. Giza C, Hovda D. The Neurometabolic Cascade of Concussion. J Athl Train. 2001;36(3): 228–235. 5.Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly JP, McCrea M, Putukian M, Valovich McLeod TC. National Athletic Trainers’ Association position statement: management of sport-related concussion. J Athl Train. 2004;39(3):280-297. 6. Harmon KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring SA, Roberts WO. American Medical Society for sports medicine position statement: concussion in sport. Br J Sports Med. 2013;47(1):15-26.
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balance between science and nature.
Restoring the
t
ORTHOVISC® High Molecular Weight Hyaluronan is the only non-avian hyaluronic acid (HA) with up to 26 weeks of efficacy1
t
ORTHOVISC® demonstrated statistically and clinically significant symptom improvement in patients with knee osteoarthritis1
ORTHOVISC® has
50-88% more HA2-6 than any available viscosupplement
1-800-382-4682 | www.orthovisc.com | www.orthoviscline.com Important Safety Information ORTHOVISC® High Molecular Weight Hyaluronan is indicated in the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and to simple analgesics, e.g., acetaminophen. In clinical studies, the most commonly reported adverse events were arthralgia, back pain, and headache. Other side effects included local injection site adverse events. ORTHOVISC® is contraindicated in patients with known hypersensitivity to hyaluronate formulations or known hypersensitivity (allergy) to gram positive bacterial proteins. ORTHOVISC® should not be injected in patients with infections or skin diseases in the area of the injection site or joint. Strict aseptic technique should be used. The effectiveness of more than 1 course has not been established. References: 1. Brandt KD, Block JA, Michalski JP, et al. Efficacy and safety of intraarticular sodium hyaluronate in knee osteoarthritis. Clin Orthop Relat Res. 2001; 385:130-143. 2-6. Manufacturer’s full prescribing information for ORTHOVISC®, Synvisc®, Synvisc-One®, Hyalgan®, Supartz®, and Euflexxa.TM Hyalgan is a registered trademark of Sanofi-Synthelabo; Supartz is a registered trademark of Seikagaku Corporation; Synvisc and Synvisc-One are registered trademarks of Genzyme Corporation; Euflexxa is a trademark of Ferring Pharmaceuticals, Inc.
ORTHOVISC® is manufactured by and is a registered trademark of Anika Therapeutics, Inc., Bedford, MA 01730. © DePuy Synthes Mitek Sports Medicine, a division of DOI 2013. All rights reserved. Printed in USA.
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