Friday, May 27, 2016

Preventing Common Summertime Injuries

Lawnmowers - wear closed toe shoes, keep young kids a safe distance away while mowing.  Most common injuries are foot lacerations, hand lacerations, and loss of toes and fingers.

Climbing ladders is likely the most dangerous thing you do- wear lace up shoes and do not go above the marked safety level  -  Common injuries include ankle fractures, foot fractures, and sometimes hip fractures.

Bike Riders are fragile, even when you are in the right - Use you light on summer nights, wear a helmet and drivers, please yield 3 feet to a bicyclist.  And slow down in the neighborhoods - lots of kids are on bikes in the summer - head injuries, wrist fractures, clavicle fractures and rib injuries happen a lot.

And our new favorite - Distracted Walking- texting or impaired hearing from loud earbud sounds impair your visual and hearing senses - Bad injuries occur when people walk into cars or off the road/sidewalk/hiking trail/escalators/parking lots.

Have a fun summer and be safe.  

Friday, May 20, 2016

ACL Facts and Figures

40,000 ACL reconstruction surgeries per year.

Yearly monetary cost 3 billion dollars.

Profound physical, emotional and financial consequences for patients and their families.

Risk of development of Knee Arthritis is high with both symptoms and xray findings of knee oa, and this happens irrespective of surgical intervention.

ACL injury prevention is the elusive holy grail for this serious knee injury.

Female athlete ACL injury rate 5 time greater than males (post puberty).  Likely explanation is anatomical, hormanal and neuromuscular differences.

Having one ACL injury increase odds 15 fold for second ACL injury (same or opposite knee).

Plyometrics, balance and core training play a role in ACL injury prevention.

Friday, May 13, 2016

Total Knee Replacement: Lowering Risk of Readmission

The top 5 reasons for readmission to the hospital at both 30 and 90 days after Total Knee Replacement are: Wound infection, deep infection, atrial fibrillation, cellulitis and abscess of leg, and pulmonary embolism.

Methods and strategies to lower these risks include no knee replacement surgery on patients with BMI higher than 40, no blood transfusions, Same day surgery or one night hospital stay, and surgeon/facility volume of greater than 100 cases per year.

At Advanced Knee Care we support/educate our patients and use non surgical modalities to help our patients stay mobile as they lower their BMI (35 is better than 40).  TXA (IV tranexamic acid) intra-operatively has virtually eliminate the need for blood transfusions.  Dr. Tarlow is a early adopter of same day total knee replacement (or one night stay).  His case volume exceeds the 100 case threshold.

Not every patient is a reasonable surgical candidate due to high predicted surgical risk .  These are serious complications that really occur following total knee replacement.  Most of the serious adverse outcomes can be avoided by utilizing appropriate patient selection criteria (the data is based on strong science).  Complications are expensive and carry a high emotional and social cost to our patients.  Heed the data.  Physicians and patients must act responsibly.

Friday, May 6, 2016

Anterolateral Ligament Knee Reconstruction

The "new" knee ligament rediscovered in 2013 by Dr. Steven Claes of Belguim has clinical importance for patient's with an ACL injury of the knee.  Exactly what the role of this ligament is not fully understood.  A small percentage of patient's in my practice (usually severe initial ACL tear manifest with large "pivot shift lesion" or in some revision ACL cases in which a well placed graft tears) undergo ALL reconstruction.

Dr. Laprade has anatomic photos and further insight into this structure.

Two papers presented at the March AAOS meeting add to our knowledge.  The first, from Drs. Rahnesmai-azar and Musahl from Pittsburgh conclude the "the decision to perform additional extra-articular reconstruction surgery should be carefully determined and further research is  needed".

The second, from Dr. Nitri of Italy observed "ALL reconstruction performed with ACL reconstruction restored the rotatory stability of the knee".

Sunday, May 1, 2016

Steph Curry, MCL, PRP and Stem Cells

Below is an excerpt from a Wired online article discussing PRP and stem cells and what the role is for regenerative treatments when treating knee injuries.

PRP (platelet rich plasma) has been scientifically studied for several years.  The fascination with this regenerative technique is based on science that shows PRP may act as a stimulator of healthy cells by releasing chemical signals that switch these cells “on”.  This may tissue to repair itself.  These signals regulate growth and development of cells including growth factors that are present in platelets termed PDGF, TGF-ß, and VEGF (to name a few).  Alpha granules from PRP are a source of cytokines that stimulate cell migration, proliferation and maturation.  However, PRP has never been shown in a high quality scientific study to improve an athlete's recovery after an MCL or ACL sprain/tear/injury.  There is some data supporting the use of PRP in articular cartilage injury and tennis elbow injury.  

Stem Cell biology is an entirely different type of regenerative medicine therapy.  Stem Cell therapy is "not ready for prime time" use knee injuries in 2016.  The science is still being worked out to discover what (if any) is the best application for this technology.

A low grade MCL sprain typically heals in 1-6 weeks with traditional modalities.  Steph will have access to the best professionals, facilities, medications and modalities to rapidly diminish the pain, inflammation and swelling of his knee while guiding him through an aggressive rehabilitation program.  One would predict Steph Curry to return to competitive play within this time frame without the need for "heroic measures".

Quoting from Luke Whelan of Wired:
"After diagnosis, they’ll try to decrease swelling with ice, compression, and anti-inflammatory drugs, and protect the injured area with tape and braces. That might be enough to get the player back on the court if the pain is manageable. But, like in the case of Curry, the physician might call for testing to see if more treatment is necessary. MRIs can estimate the water content in different tissues to create a 3-D image of the body part. For a knee, it provides a picture of a ligament sprain, soft tissue bruise, or cartilage damage.
Extreme Measures
That’s all pretty standard—the kind of treatment you might get as an active recreational athlete, just with quicker test turnarounds. But with intense pressure to get back to play as fast as possible, many professionals go a step further, turning to new, rarer therapies. “We may do things with professional athletes that are maybe not proven,” says Cole, “like regenerative medicine.”
The most popular of these therapies is platelet-rich plasma (PRP) injections, which are concentrated with growth factors that might help to speed healing. Doctors also use more invasive stem cell injections, sticking a needle into the hip bone to suck up bone marrow cells and then inserting them into the injured tissue. Cole maintains these injections have shown some benefits for healing and, at the very least, haven’t shown evidence of being harmful.  
But others are skeptical. “There are some situations where it’s not utilized in a biologically sound way,” says Luke. “Everyone is always looking for the newest cutting-edge technique that might save a few days or a magic bullet that might fix this.” He cautions athletes from using therapies like PRP injections in the place of giving the body enough time to heal."