Orthopaedic News

Lumbar Hyperlordosis

Lumbar lordosis refers to the inward curvature of the lumbar spine that is created by wedging of both the lumbar intervertebral discs and the vertebral bodies.

Deviations of the lumbar spine such as an increased lumbar lordosis have an impact on overall postural stability particularly in maintaining sagittal balance due to a degeneration of the sagittal spine curvature.

A greater lordosis angle is a risk factor for developing spondylolysis and ventral bulging of the affected vertebra, with researchers having proved a positive association between lumbar hyperlordosis angle and spondylolysis and isthmic spondylolisthesis.

Been and Kalichman gave a detailed description of the anatomy of lumbar lordosis stating that dorsal wedging of the vertebral bodies and discs increases the lordosis angle, whereas more ventral wedging of these structures reduces the lordosis angle ……………. Continue reading on mass4d.com: Lumbar Hyperlordosis

Nail Simplifies Two-Procedure Rotator Cuff Repair

A significant number of proximal humeral fractures occur with soft tissue injuries of the rotator cuff. Historically, fractures were treated separate from cuff tears with two procedures. Each procedure required different techniques and individual instruments. An innovative new utility patent has been issued to Dr. Michael Levy for the creation of a technology that bridges the concept of treating the fracture and the rotator cuff. This patented implant combines a flexible humerus nail with an external tab to aid rotator cuff repairs. This patent design work allowed him to get back into implant design, and integrate his surgical experience.

Prior to advances in bone and soft tissue anchors, implants, and arthroscopy, rotator cuff surgery was primarily performed via open incisions and cumbersome suture techniques. Operative treatment for the proximal humerus has run the gamut from pinning, plating, and nailing, to forward and reverse arthroplasty. Nails for the proximal metaphysis of the humerus have undergone a wide spectrum of design ideas including semi-rigid and flexible nails with and without cross locking. Little has been done to combine cuff repairs and fracture fixation.

Past treatment of both injuries involved a flexible nail that accepted sutures to hold down the cuff and cover the humeral head. This is commonly known as the parachute technique, employing two Enders flexible nails in the proximal humerus. The inspiration for the new patented nail with a tab was to simplify the cumbersome suturing required for cuff repairs, and incorporate an updated, more versatile nail with better fixation options.

The current nail design comes in three lengths: 240 mm, 260 mm, and 280 mm. The nail is designed with three staggered proximal holes angled for humeral head cross locking screw fixation. The proximal portion of the nail is 9 mm, while it tapers distally to 4 mm for ease of implantation. The flexible nail can be driven into the distal humerus, negating the need for difficult and dangerous distal cross locking. A locking dovetail holds the tab in position on the lateral footprint of the rotator cuff tear. Sutures pass through holes in the tab for ease of use.

Type of Knee Ligament Injuries

Our knee is made up of many important structures, any of which can be injured. The most common knee injuries include fractures around the knee, dislocation, and sprains and tears of soft tissues, like ligaments. In many cases, injuries involve more than one structure in the knee.

Anterior Cruciate Ligament (ACL) Injuries

The anterior cruciate ligament is often injured during sports activities. Athletes who participate in high demand sports like soccer, football, and basketball are more likely to injure their anterior cruciate ligaments. Changing direction rapidly or landing from a jump incorrectly can tear the ACL. About half of all injuries to the anterior cruciate ligament occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments.

Posterior Cruciate Ligament (PCL) Injuries

The posterior cruciate ligament is often injured from a blow to the front of the knee while the knee is bent. This often occurs in motor vehicle crashes and sports-related contact. Posterior cruciate ligament tears tend to be partial tears with the potential to heal on their own.

Do spine fusion patients with hip arthroplasty risk dislocation?

Anew study of 42,300 patients explores the question of whether patients undergoing lumbar spinal fusion (LSF) before total hip arthroplasty (THA)—versus after—have an increased risk of dislocation and revision.

Study co-author Arthur Malkani, M.D. of the University of Louisville Adult Reconstruction Program, explained to OTWthe rationale for this large study: “There has been a significant increase in the number of patients undergoing primary THA with a history of prior lumbar spine fusion. Lumbar spine fusion is an independent risk factor for dislocation leading to increased risk of revision.”

“The prevalence of hip dislocation following primary THA in patients with prior lumbar spine fusion in the Medicare population is 7.4%. Lumbar spine fusion alters spino-pelvic anatomy leading to loss of the normal pelvic parameters during standing and sitting which could lead to hip impingement and instability.”

In the study, 28,668 patients underwent lumbar spine fusion and then total hip arthroplasty sometime later and 13, 632 had the reverse—total hip arthroplasty followed by lumbar spine fusion sometime after.

Dr. Malkani told OTW, “In our practice we are seeing more patients presenting with both lumbar spine disease and primary hip osteoarthritis. The purpose of this large database study was to determine if hip instability could be decreased if the hip replacement was done first prior to the lumbar fusion in patients with both lumbar spine disease and hip arthritis.”

“The results from this study suggest a significant advantage for patients to undergo THA first if concomitant lumbar spine and hip pathology are likely to require both lumbar spine fusion and THA.”

“There was a 46% increased risk of dislocation in patients with prior LSF compared to the group that had a THA done first followed by a LSF within 1 year, 60% increased risk of dislocation compared to THA first then LSF at 2 years and 106% increased risk compared to THA first and delayed LSF by 5 years. The greater the interval between index THA and proceeding LSF, the lower the risk of dislocation and THA revision.”

“Instability continues to be the leading cause of failure following primary THA leading to revision surgery. We need to identify high risk patients for instability prior to the primary THA. We need to start asking patients if they have any history of lumbar spine disease during the initial visit prior to the THA. In those patients with concomitant lumbar spine disease and hip osteoarthritis, the arthroplasty and spine surgeons need to collaborate to determine if the hip arthroplasty can be approached first with a delay in spine surgery.”

“Additional work is required to determine the ideal functional acetabular cup position in patients with a rigid lumbosacral-pelvic biomechanical relationship and altered pelvic parameters. Surgeons should look at multiple factors in patients undergoing THA with a history of prior lumbar spine fusion to minimize dislocation such as preoperative assessment of pelvic parameters, ideal surgical approach, maximizing head size, restoring offset, satisfactory implant alignment, and an intraoperative assessment of stability.”

spinal-stenosis I Orthopedic Implant Blog

Do You Have Lumbar Spinal Stenosis?

Lumbar spinal stenosis (LSS) is a common cause of pain in the lower back and legs. As we get older, our spines go through changes. This is known as spinal degeneration, and it happens to everyone. That being said, even though it happens to everyone, not everyone has negative symptoms that accompany it. When our spines degenerate, the spinal canal may narrow, leading to a condition known as spinal stenosis.

Age-related spinal wear and tear occurs in 95% of people by the age of 50. However, spinal stenosis usually occurs in adults age 60 and older. When the spaces surrounding the spinal canal narrow, it may put pressure on nearby nerves, causing pain. Pressure such as this affects both genders equally.

A minority of patients are born with congenital back problems that later develop into lumbar spinal stenosis. Appropriately, doctors refer to this form of the condition as congenital spinal stenosis. Usually, this form of the condition occurs in men, but it may occur in women as well. For congenital spinal stenosis, symptoms typically manifest between the ages of 30 and 50.

Lumbar Spinal Stenosis Causes

Out of all possible causes, degenerative arthritis is the most common culprit of spinal stenosis in patients. For context, arthritis refers to the degeneration of any joint at any point in the body.

In our spines, arthritis results from disc degeneration and the loss of water content. In younger patients, spinal discs have a higher level of water content. However, as patients grow older, the discs begin to dry out, and in turn, they weaken. This may lead to a slew of other problems, such as lumbar radiculopathy or degenerative scoliosis.

As the spine settles, the weight transfers to the facet joints. Additionally, the tunnel that the nerves exit through becomes smaller. As the joints experience increased pressure, the cartilage that protects these joints wears away. If it wears away completely, it results in bone rubbing on bone and causing pain.

When the body loses cartilage in this manner, it may also try to make up for the lost bone by growing new bone in the facet joints. This may sound like a good thing, but it actually leads to the formation of bone spurs. These bony protrusions may put additional pressure on nearby nerves, leading to unpleasant symptoms.

In some cases, the body may respond to arthritis in the lumbar spine by increasing the ligaments around the joints in size. This is known as facet joint hypertrophy, and it also lessens the space surrounding the nerves in the spine. Once the surrounding spaces become small enough, it may irritate the spinal structures.

From : njspine.com

Exercise After Hip Replacement

To achieve full recovery after a hip replacement it is vital that you incorporate regular exercise into your life. Regular post-operative exercise will allow you to return to your everyday activities within 3-6 weeks after surgery; and return to driving at six weeks. These exercises are geared to restoring your blood flow, strength and mobility. Moving forward it is important to gradually increase walking, sitting, standing, and climbing stairs.

Your orthopedic surgeon will work with your physical therapist to create a plan for you.

During early recovery, while you are in the hospital, you will begin to walk short distances in your room to help your hip to regain its strength and movement.

Post- operative exercise

Walking

Walking is the best exercise for a healthy recovery, because walking will help you recover hip movement. Initially, the use of a walker or crutches will help to prevent blood clots and strengthen your muscles which will improve hip movement. To ensure you are walking properly you will receive guidance from your surgeon or therapist about how much weight to put on the leg. You will be able to more weight on your operated leg as your strength and endurance improve.

While exercise may be painful at first, it can reduce post-op pain, improve blood flow and speed recovery. This will also reduce swelling in the calf and ankle. Swelling can last up to 3 months.

We recommend that you walk two to three times a day for about 20-30 minutes each time. You should get up and walk around the house every 1-2 hours. Eventually you will be able to walk and stand for more than 10 minutes without putting weight on your walker or crutches. Then you can graduate to a cane.

Climbing Stairs

Stair climbing is a great way to increase your strength and endurance. Always use your hand rail and do not try to climb any steps that are higher than 7″. Using a crutch on the opposite side from your surgery, climb up leading with your good leg. Putting weight on the crutch, raise your operated leg and place it on the step. Moving slowly one step at a time.

Going down lead with your operated leg, putting your weight on the crutch. Eventually, you will become stronger enabling you to climb the stairs foot over foot.

Early Post-op exercises

Lying Down:

Ankle Pumps- This exercise should be done right after surgery, and until you are completely recovered. Point and flex your ankles often, at least once per hour.
Ankle Rotations- move the ankle inside and outside away from the other foot. Do these 5 times in each direction, 3 to 4 times per day.
Knee Bends – lying on the bed with your leg straight out in front of you, pull your foot toward your buttocks keeping your heel on the bed. Hold in this position for 5-10 seconds, then straighten the knee keeping your heel on the bed.
Buttock Tightening- Lying on your back, contract your buttocks muscles and hold for a count of 5. Release and repeat 10 times a day.
Abduction exercises- slide your leg out to your side as far as you can away from your body, and then slide it back. Repeat 10 times per day.
Quadriceps – Lying on your back, tighten your thigh muscles. Try to straighten your knee. Hold for 5-10 seconds. Repeat 10 reps in 10 minutes, resting one minute, then repeat. Stop when your thigh feels fatigued.
Straight leg raises- tighten your quads keeping your knee straight. Lift the leg a few inches. hold 5-10 seconds. Lower the leg. Repeat until your thigh feels fatigued.

Standing Exercises

Knee raises. Standing behind a chair and hold the back of the chair for support, raise the knee toward your chest only to waist height. Hold for a count of 2-3 and put the leg down.
Standing hip abduction. Holding the back of a chair for support, raise your leg out to the side, hold and slowly lower to the floor. Do 10 repetitions. Repeat 3-4 times a day.
Standing Hip extensions. Again, holding the back of a chair for support, Lift the leg back behind you, keeping the leg and back straight. Hold for 2-3 counts. Release and return the foot to the floor. Do 10 repetitions. Repeat 3-4 times a day.

After about a month of strengthening your hip muscles, you will receive a list of exercises using resistance with an elastic tube. You may also be instructed to ride an exercise bike. Speak with your Ortho Illinois surgeon, and or your physical therapist regarding when you will be ready for these more advanced exercises.

Reference From : www.orthoillinois.com

Childhood exposure to passive smoking and bone health in adulthood. The Cardiovascular Risk in Young Finns Study

In this longitudinal study, researchers investigated the independent effects of exposure to passive smoking in childhood on adult bone health. Participants included 1,422 people who were followed up for 28 years from baseline in 1980 (age 3-18 years). Peripheral bone characteristics were evaluated in adulthood using quantitative computed tomography (pQCT) in the tibia and radius, and calcaneal mineral density was estimated by quantitative ultrasound. Children whose parents smoked and had high levels of cotinine had a significantly lower bone sum index derived from pQCT vs smoking parents with low levels of cotinine. According to findings, children of smoking parents having a greater risk of experiencing bone health impairment in adulthood.

Reference From : www.mdlinx.com/

TKA: Local Injection Anesthesia vs Femoral Nerve Blok

Femoral nerve block or local infiltration (injection) anesthesia for total knee arthroplasty (TKA) patients—which works better?

Dr. Alessandro Paglia, faculty member with the Department of Life, Health and Environmental Sciences, University of L’Aquila, as well as the Department of Mini-invasive and Computer-assisting Orthopaedic Surgery at San Salvatore Hospital and study co-author explained to OTW the purpose behind the study: “TKA is a surgical procedure that leads to a lot of pain in the postoperative days. We are looking for a standardized protocol for pain management to apply to all patients.”

For their study, the investigators enrolled 51 patients into a three-arm, randomized prospective study. Group 1 (the control group) received no analgesic protocol. Group 2 received an intraoperative local infiltration anesthesia (LIA). Group 3 received a femoral nerve block (FNB).

Dr. Paglia and his colleagues reported that the, “local infiltration anesthesia and femoral nerve block groups both showed a significant reduction at VAS [Visual Analog Score] score, better range of motion and less morphine consumption than the control group. The local infiltration group reported a constant pain control in the postoperative days; the femoral nerve block group reported good pain control in the hours after surgery, but decreased efficacy in the following days.”

Dr. Paglia told OTW, “Our results show how the local infiltration is a good strategy. There are a lot of ways of treating pain after TKA but it is still not possible to understand what could be the best. At the moment we are studying the block of adductors compared to other strategies; it seems to have an excellent analgesic effect on the first day with the appearance of important pain after 48 hours.”

“Perhaps it would be better to always have a minimum of constant pain with which the patient has to live rather than have two days of complete well-being.”

Network of proteins influences the advancement of osteoarthritis

A network of carbohydrate binding proteins – so-called galectins – plays an important role in the degeneration of cartilage in osteoarthritis. A research group at the MedUni Vienna was able to demonstrate this correlation, in cooperation with international study partners. In osteoarthritis, certain galectins are produced by the cartilage cells themselves and accelerate the degeneration process of the cartilage matrix.

Whilst galectins do play a role in cartilage development during childhood growth, they essentially do not occur in healthy adult cartilage. Now discovered that the quantity of galectin-8 found in the cell samples was correspondingly greater with an increasing severity of cartilage degeneration. After its production, this protein is released by the cartilage cells and connects with the cell surfaces, where it causes inflammatory processes and accelerates the matrix degradation of the cartilage tissue. Other galectins, which are otherwise able to perform various functions in the cell, apparently also play an accelerating role here.

Source: Medical University of Vienna

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