Tommy John Surgery

By  aenriquez  published  June 12, 2019

When people think of major league baseball pitcher Tommy John, two things might pop into their minds. The first has to do with his baseball career, which was certainly an exemplary and enduring career that included a record (at the time) for a pitcher of 26 seasons in big league baseball. The second thing people associate with Tommy John is the surgery that bears his name.

 

John’s career included participation in three dramatic Worlds Series between the Los Angeles Dodgers and the New York Yankees. Twice he was voted as a baseball All-Star. But one statistic from his career has been the focus of speculation for many years, which is John’s pre-operation success on the pitcher’s mound and his post-operation success.

Any surgical procedure needs to be thoroughly discussed with qualified physicians, and elective surgery is not an exemption to that rule

Before And After Surgery

Prior to surgery, which took place in 1974, John had notched 124 victories as a major league pitcher. After taking a year off to recuperate, John returned in 1976 and from then on amassed 164 more wins. As such, the operation not only worked, but it gave rise to speculation that John threw the ball harder after the surgery than before.

 

John’s comeback from surgery was startling in its success and the pitcher’s longevity. And it wasn’t long before parents of healthy young baseball prospects were requesting the operation for their offspring, hoping the elective procedure would turn their child into a major league baseball player.

 

Buyer Beware

 

Any surgical procedure needs to be thoroughly discussed with qualified physicians, and elective surgery is not an exemption to that rule. Certainly, if you could buy a bionic mechanism that could turn your child into a baseball star, people would line up around the block to grab a hold of that slice of the American Dream. Only your physician and yourself can make the call on whether or not to go through with that option. Here, let’s discuss how the procedure works.

 

Ulnar collateral ligament reconstruction surgery

 

Recommended if the ulnar collateral ligament is frayed or stretched beyond healing, this reconstruction surgery was first performed on Tommy Johns by Dodgers team physician Frank Jobe. Technically, the procedure is a surgical graft. This entails replacing the damaged ligament with a tendon taken from a donor or from another portion of the patient’s body.

 

Needless to say, if the tendon is taken from the patient’s body, the physician selects one that will not have a major negative impact when removed. The tendons commonly used are the patellar tendon, which comes from a knee joint, or the palmaris tendon, selected from the opposite forearm.

 

The procedure involves drilling holes in the ulna and humerus bones of the elbow, then wrapping the donated tendon through the holes in a figure eight fashion. The ends of the tendon are then anchored in place. At times, the procedure also involves moving the ulnar nerve, which is made necessary if the new scar tissue is likely to push on the nerve causing post-operative pain.

 

Not Just for Pitchers

 

Pitchers are not the only baseball players prone to ulnar collateral ligament distress. The condition, however, is predominantly a baseball-specific injury. For pitchers, the recovery time is more significant for pitchers than for other players.

Meanwhile, the rise in ulnar collateral ligament procedures on youth – elective or not – has been on the rise, prompting Major League Baseball and Little League Baseball to encourage injury prevention pitching by following a program called Pitch Smart.

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Shoulder Replacement Surgery For Younger Patients

By  aenriquez  published  June 4, 2019

Shoulder replacement surgery – called a shoulder arthroplasty – has traditionally been relegated to helping elderly patients who suffer from long-term arthritis that is leading to the deterioration of cartilage and possibly bone structure. However, doctors now see advancements in both material and technique may allow the option to be extended to select younger patients. Let’s see if you are a candidate for this type of operation.

Structure

The shoulder is a ball and socket style joint with a design that is likely not quite what most people imagine. While many envision a ball and socket as a mechanism that includes a socket wrapping almost completely around a ball, the shoulder has a ball that simply rests against a slightly concave structure, held in place by muscles and a series of tendons and ligaments. Picture a round-bottomed cup resting against an almost flat saucer, held there by rubber bands. The saucer doesn’t wrap around the cup, it provides a settling place for it and, under normal conditions, it stays where it is while allowing for a wide range of motions.

There are pros and cons of each procedure, which should be discussed thoroughly with a physician

The joint, however, is not a system in which bone moves against bone. This occurs when debilitating conditions, like arthritis, become advanced. Normally, a shoulder joint includes healthy cartilage that allows for smooth motions.

Conditions Change

Arthritis is a condition marked by painful movement owing to the deterioration of cartilage. This can occur with age, but it can also be accelerated by prolonged athletic activity. As such, some of the more dedicated athletes – because they practice or play a lot – develop arthritis prematurely.

Doctors, however, have traditionally been reluctant to recommend shoulder replacement surgery for someone who is still young. The reasons for this included the expectation that wear and tear of the replacement material, a metal ball and a plastic cup that allows for smooth motion — would eventually wear out, requiring a second operation.

Doctors at the Mayo Clinic now say that carefully selected younger patients could benefit from shoulder replacement surgery. Here are the criteria that doctors should look for when selecting a younger patient for this type of operation:

  • healthy rotator cuff that can hold the new joint in place
  • Healthy socket bone stock (called the glenoid bone)
  • Intact deltoid muscle
  • Persistent pain that does not respond well to conventional treatment
  • A patient motivated to complete physical therapy for post-operative healing and restoration

Discussions

Patients should be aware of the options for a shoulder arthroplasty before selecting the right procedure for them. There are pros and cons of each procedure, which should be discussed thoroughly with a physician.

The options for surgery include a traditional shoulder arthroplasty, a partial shoulder replacement in which just the ball is replaced and a reverse shoulder arthroplasty.

Reverse Arthroplasty

Doctors came to the realization that the ball, which is normally the terminal part of your arm, and the socket, which is on the proximal side, could be reversed. In fact, it is beneficial to reverse the ball and the socket in conditions in which there is a complete rotator cuff tear, which no longer functions well to hold the joint in place.

The gains of a reverse shoulder arthroplasty is better stability when there is little or no functioning soft tissue that can hold the joint together.

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Considering Joint Replacement Surgery? As Your Local AI

By  aenriquez  published  May 31, 2019

Let’s preface this news with the clear understanding that patients undergoing total knee or total hip replacement surgery should consult with their physicians and ask every question they can think to ask. Then ask a few more questions. Then ask a few more.

However, to whom shall your physician go to ask questions? It turns out, the answer to that may well be to a machine. The reason: A new study conducted at the Hospital for Special Surgery in New York City found that computers plowing through various algorithms could reasonably predict which patients undergoing these two critical operations would benefit from the surgery and which ones would not.

Predicting the outcome is not always easy for man or machine, but there may be better outcomes if the two work together

“Machine learning has the potential to improve clinical decision making and patent care by helping prioritize resources for post-surgical monitoring and informing pre-surgical discussions of likely outcomes,” the study found. In so many words, that means, patients should ask their doctors every question they can think up. Doctors, on the other hand, would do well to consult the Oracle, which is to say, they should turn to their computers to help guide their decisions.

Predicting the outcome is not always easy for man or machine, but there may be better outcomes if the two work together. This should never mean allow the computer to take a decision out of your hands. But algorithms in the study did have reasonable predictions concerning whether or not patients, two years after surgery, were benefiting from the knee or hip replacements.

The study was lengthy and included thousands of patients. The data collected involved 7,239 hip replacement surgeries and 6,480 knee replacement surgeries done between 2007 and 2012. According to a press release, “using data about both physical and mental status of patients before and two years after procedures, the investigators were able to calculate whether a patient achieved an MCID across four patient-reported outcome measure scores.” Those scores included self-reporting assessments of general physical health, general mental health, plus measures for hip health and knee health.

An MCID, meanwhile, is a clinical term for “did it work?” Technically, MCID stands for minimal clinically important differences. So, maybe the better translations would be: “did you even notice that the surgery worked?”

Of course, this may be the type of study that will not cause much excitement in the general public, which includes those too cynical to believe these predictions are possible and those who assumed computers were helping orthopedic surgeons make critical decisions all along. But, the point for physicians is a bit more important, because doctors live so close to the action that any miscalculation in this regard is considered a very bad day at work.

Nobody likes unnecessary surgery, but especially so if predictions of outcomes are made easier or more accurate. “The least valuable health care is that which is not wanted or needed,” said one of the senior authors of the study Catherine MacLean, MD, Ph.D., HSS, Chief Value Medical Officer at the hospital.

“Accurate prediction of whether individual patients will achieve a meaningful improvement after the procedure will greatly assist patients and their physicians in determining the best course of therapy,” MacLean said.

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Regenerative Medicine can relieve your Joint Pain

By  david@ogrelogic.com  published  May 22, 2019

Are you considering surgery for your chronic knee or other joint pain? Have you tried conservative treatments but not obtained enough relief? Maybe you should consider Regenerative Medicine. Innovative and advanced regenerative medicine treatments, such as PRP therapy, can enhance the body’s natural healing ability, providing remarkable solutions for all types of joint pain.

The body uses natural growth factors and stem cells to repair and regenerate tissues. These can be obtained from your own body in the form of PRP (Platelet Rich Plasma) or stem cells. Platelet-rich plasma is derived from blood taken from the person’s own body. Platelet rich plasma contains platelets and growth factors essential for healing.

How does PRP treatment help with joint pain?

Chronic joint pain is often the result of loss or wear and tear of the smooth, articular cartilage that helps the bones of a joint glide over each other during movement. Joint pain is mainly caused by osteoarthritis or inflammation of the joint due to rubbing of the bones against each other. Pain may result from injury to the soft tissues surrounding the joint such as ligaments, tendon, and bursae.

When fluoroscopy-guided injections of PRP are administered into a joint over a period of time, the cartilage regenerates, pain reduces and joint function improves.

Regenerative medicine treatments allow deep tissue healing and can be used to effectively treat joint pain and delay the need for surgery. Discuss with your orthopedic if regenerative medicine options are right for you.

 

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Pathologic Fractures

By  aenriquez  published  May 2, 2019

A pathologic fracture may be defined as a break in a bone caused by an underlying disease. An otherwise healthy bone typically fractures as a result of trauma. A diseased bone may do so either without trauma or due to minimal trauma. Diseases of the bone that predispose bones to fracture easily include osteoporosis, osteomyelitis, osteomalacia, Paget’s disease and malignancy (primary or secondary).

 

Pathologic fractures can affect any bone that is diseased, and the symptoms depend on the type and location of the bone involved. Many diseases affect the spinal vertebrae, which are prone to pathologic fractures, which can cause a range of symptoms from pain in back, legs, and arms to neurological impairment, such as numbness and/or weakness in the arms or legs.

Pathologic fractures can affect any bone that is diseased, and the symptoms depend on the type and location of the bone involved

Pathologic fractures are detected on imaging, which is initiated either by a suggestive history and physical exam or staging, restaging or surveillance workup for cancers.

 

  • X-ray – plain film radiographs provide an overall assessment of bone integrity and the presence and the extent of the fracture. It can also detect spinal dislocation or slippage, kyphosis, scoliosis, etc. In addition to these, it can detect specific bony abnormalities such as bone spurs, disc space narrowing, vertebral body fracture, collapse or erosion, etc. Dynamic or flexion/extension X-rays may help in detecting any abnormal or excessive movement or instability in the spine at the affected levels.
  • Computed tomography scan (CT scan) – shows more detailed images of the bones and the soft tissue, and is best suited for evaluating the extent of the fracture.
  • Magnetic resonance imaging (MRI) – is more suitable for evaluating soft tissue damage occurring as a result of the fracture. It is especially useful for the detection of neural damage. MR (or CT) angiography is considered when vascular compromise is suspected.
  • Nuclear bone scan – this scan can be helpful when surveilling for distant bone metastases, in addition to detecting bone infections, especially when MRI is not possible.

 

The goals of treatment are pain relief, reversal or stabilization of neurological deficits and stabilization. For less severe pathologic fractures, nonoperative/conservative management is considered. Severe pathologic fractures require surgical treatment, and the choice of procedure is based on the location of the bone and the extent of the injury. Spinal pathologic fractures can lead to collapsed vertebrae and vertebroplasty or kyphoplasty is required, during which a cement mixture is injected into the fractured bone to stabilize the fracture, treat pain, and prevent further spinal deformity from progressing. In cases where the collapsed vertebrae impinge on the nerve roots or the spinal cord itself, the surgeon may need to remove diseased bone to relieve pressure and possibly perform a spinal fusion to stabilize the spine until it heals. The underlying disease process needs to be adequately managed as well – whether it’s bisphosphonates for osteoporosis or suitable cancer treatment for metastatic disease.

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Sacral Fractures

By  aenriquez  published  April 25, 2019

The sacrum is formed by the fusion of 5 sacral vertebrae and articulates with 5th lumbar vertebra proximally and coccyx distally, and with ilia at sacroiliac joints bilaterally. It contains 4 foramina which transmit sacral nerves (L5-S5), which are responsible for the functions of anal sphincter tone / voluntary contracture, bulbocavernosus reflex and perianal sensation. As an osseous structure, sacrum transmits the load distributed by the first sacral segment through iliac wings to the acetabulum.

Sacral fractures are quite common, occurring in up to 45% of pelvic ring injuries related to high energy trauma (in young adults) or low energy falls (in elderly). They are often underdiagnosed and as a consequence, they are frequently mistreated and lead to serious complications such as neural damage (25% of all cases).

Transverse sacral fractures also have a high incidence of nerve dysfunction

The presence of a neurologic deficit is the most single most important factor in predicting the outcome. Untreated fractures with neurologic deficits lead to symptoms of lower extremity motor/sensory deficits and/or urinary/rectal/sexual dysfunction.

Sacral fractures are classified according to the Denis classification. Zone 1 fractures (50% of all) are lateral to the foramina and are least related to a nerve injury. Zone 2 fractures are through foramina, and based on whether they are stable or unstable, have an increased risk of nonunion, nerve damage and poor functional outcome. Fractures that are medial to foramina are associated with the highest rate of neurological deficit (60%), such as bowel, bladder, and sexual dysfunction. Transverse sacral fractures also have a high incidence of nerve dysfunction.  The u-type sacral fractures result from axial loading and represent spino-pelvic dissociation; these too have a high incidence of neurologic complications.

The clinical diagnosis begins with taking a proper history – motor vehicle accident or fall from height are the most common causes of these fractures, but repetitive stress, insufficiency fracture in osteoporotic adults are also important predisposing factors. The most prominent symptom is peripelvic pain. The physical exam should include testing for pelvic ring stability by internally and externally rotating iliac wings, palpating for subcutaneous fluid mass indicative of lumbosacral fascial degloving, as well as performing a vaginal exam in women to rule-out open injury. A focused neurologic, vascular and rectal exams are also important to assess the degree of tissue damage.

Radiographs are required to diagnose a sacral fracture, although only 30% show sacral fractures. CT is by far the diagnostic study of choice for proper assessment of the fracture, while MRI is considered when neural compromise is suspected.

Nonoperative management includes progressive weight bearing with orthosis if needed, and can only be considered in patients with <1 cm displacement and no neurologic deficit, and in cases of insufficiency fractures. Surgical fixation (without decompression) should be considered if there is a displaced fracture >1 cm with associated soft tissue compromise and persistent pain after non-operative management, and also if there is displacement of fracture after non-operative management. Surgical fixation with decompression is the treatment of choice whenever there is evidence for neurologic injury.

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When is it time for Orthopedic Surgery?

By  david@ogrelogic.com  published  April 16, 2019

Every year orthopedic surgery allows millions of people suffering from debilitating injury or disease to return to their normal lifestyle.

Any type of surgery on the musculoskeletal system, performed to treat painful symptoms or restore mobility may be considered orthopedic surgery. Orthopedic surgery includes a wide range of procedures, from the repair or removal of torn ligaments and tendons to complex procedures, such as joint replacement surgery.

However, many people suffering from painful, degenerative joint diseases or painful injuries are unaware of the benefits of orthopedic surgery. Advancements in surgical techniques allows many patients to undergo outpatient surgery and return home the same day or the day after and recover much faster than ever before.

It may be time for orthopedic surgery, if you have tried conservative treatment options ,such as medications, steroid injections, physical therapy, lifestyle modifications and still experience the following signs –

  • Persistent or returning bone and joint pain
  • Pain worsens upon with activity
  • Limited mobility
  • Difficulty with activities of daily living
  • Pain interferes with sleep
  • Grinding sensation in the joints
  • Poor quality of life due to pain, restricted mobility and inability to carry out normal activities

Why should you live with pain when orthopedic surgery offers a safe and permanent solution to many bone and joint conditions? Waiting too long to seek treatment may worsen your condition. If you have been living with an orthopedic condition that seems stubborn, visit an orthopedic doctor or surgeon to have it diagnosed and to explore possible treatment options.

 

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Meniscus Tears and Repair

By  david@ogrelogic.com  published  March 28, 2019

Meniscus is a disc-shaped cushion that keeps the surfaces of bones at the knee joints from coming in contact with or rubbing against each other. The meniscus keeps the knee joint stable and helps in movement as well as maintaining balance.

When the meniscus is damaged, it can make even daily movements painful or even cause the knee joints to lock up.

Meniscus repairs have become more successful with the development of newer tools and advanced technology.

Each knee has two menisci and they can be torn due to some form of twisting or excessive knee bending. The meniscus may get torn due to –

  • Kneeling
  • lifting something heavy
  • squatting down
  • playing basketball
  • stepping off a curb
  • aging and having arthritic damage

Large tears can cause the knee to lock up. Meniscus damage can cause knee pain and swelling due to the irritation to the joint from the unstable meniscus tissue or the excess stress to the joint from the loss of the cushioning.

Most meniscus tears do not require surgery. There are a variety of treatment options that can be effective in reducing symptoms.

Your orthopedic surgeon would determine the need for and viability of a meniscus repair for you.

After surgery, physical therapy is needed to retsore range of motion, reduce swelling and regain muscle function. After 4-6 weeks, weight bearing is gradually initiated, and a normal gait is the next goal.

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All you need to know about a Knee Replacement

By  david@ogrelogic.com  published  February 20, 2019

The decision to undergo a knee replacement is tough. Several factors need to be taken into consideration. If your doctor recommends a knee replacement procedure but you are still sitting on the fence, here are important facts things that may help you make an informed decision.

Indicators for a knee replacement

Knee replacement surgery is typically advised when –

  • the pain makes it impossible for you to sleep or perform normal, everyday activities
  • you suffer from arthritis of the knee
  • your knee is significantly damaged (e.g., due to injury)
  • other treatments have proven ineffective

Knee replacement procedure

During the procedure, you’ll be given a local (in the joint), regional (from the waist down) or general (that will make you sleep through the surgery) anesthesia. A small incision is then made in the knee. The knee is pumped with saline and a small camera or arthroscope is inserted inside the joint to make it easier for the surgeon to look inside the joint and carry out the procedure. Your orthopedic surgeon then investigates the source of the knee pain. Depending on the underlying condition, the doctor clean up or repair the joint tissues. Artificial implants are used to replace the damaged parts of the joint. The procedure presents minimal risk and has proven beneficial to a majority of the patients.

Recovery after the knee replacement

The post-surgery period is critical in terms of getting back on your feet. You have to do rehabilitation exercises at home to ensure your knee can completely recover.

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Recovering from Rib Fractures

By  aenriquez  published  February 5, 2019

Chest injuries are quite common in sports and motor vehicle accidents, and many of them cause rib fractures. Broken or cracked ribs can be very painful, but in most cases can be easily managed, unless they have penetrated into the vital organs. In many cases, fractured ribs heal on their own in a month or two, although the condition is often associated with sharp pain, which exacerbates with movement. The healing process can be augmented with limiting activity and avoiding further injury.

Another important activity that can really help is deep breathing. Fully expanding lungs using deep breathing exercises, coughing, and though incentive spirometry is very important and preventing atelectasis (or collapsed lung), which is a breeding ground for infection. A painful rib cage limits one’s ability to take full breaths, and coupled with bed rest, it can lead to atelectasis and pneumonia. Therefore, it is highly advisable to perform these activities to prevent atelectasis. Diminishing pain through over-the-counter painkillers (such as NSAIDs) can also help prevent atelectasis.

Signs of the typical complications of broken ribs - pneumonia, pleural effusion, or a punctured lung

For the first 4 to 6 weeks, the patient is advised not to lift more than 10 pounds or push/pull heavy objects. They should also avoid vacuuming, mowing, etc. Of course, that includes participating in contact sports. They are advised to do plenty of walking and perform low-impact exercise and resume normal daily activities.

 

It is critically important to look out for the warning signs, which include difficulty breathing, blue-tinged lips, fever of 102°F or higher, coughing up blood or thick mucus. If any of these are experienced, one should go to the emergency room right away, as these are heralding signs of the typical complications of broken ribs – pneumonia, pleural effusion, or a punctured lung.

 

For severe pain, opioids may have to be prescribed, but they are avoided as much as possible. This is because opioids have very high addiction potential and it may become hard to get off them. Moreover, they cause sedation and entail many precautions – including falls, handling machinery, driving, etc. They must not be taken with alcohol or other sedatives or other anti-anxiety or recreational drugs. Constipation is a very common side effect of opioids, and patients who are prescribed opioids are advised to stay well-hydrated and even take a laxative or a stool softener if needed. Ice helps decrease swelling and pain, and may even help prevent tissue damage. Use an ice pack or put crushed ice in a plastic bag.

 

In some cases, surgery may be needed if multiple ribs are badly fractured. It is definitely indicated if there is a condition called flail chest, in which the broken ribs will need to be held together with plates and screws. Also, if there is a serious injury to adjacent soft tissue, such as an organ, nerve, or blood vessel, it will require surgical treatment. And the recovery process is contingent on the extent of the injury and the type of surgical treatment.

 

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