Lovejoy M.D.

Jones Metatarsal Fracture

dlovejoy4 — Wed, 13 Apr 2011 14:58:05 +0000

The Jones fracture (named after a famous English physician) is a fracture of the shaft of the fifth metatarsal. The metatarsals are the long bones connecting the toes with the mid foot and the fifth metatarsal is the bone on the outside of the foot. The fracture occurs at the junction of the proximal and middle parts of the metatarsal bone, usually from a twisting fall, but sometimes from walking or dancing ( a stress type fracture).

The difficulty in the Jones fracture arises due to vascular anatomy. The location of the fracture is at a watershed area where the circulation from the ankle meets that from the toes, and it is poorly vascularized compared to the rest of the bone. In this situation, the bone healing can be very slow and frequently goes on to a delyed or non union of the fracture.

Treatment usually is with a cast, but if the bone does not heal either electrical stimulation of the fracture or surgical fixation with a long screw is needed. Although no one wants surgery, the long term results are very good, evn if slower that one would want

Osteoporotic Compression Fractures

dlovejoy4 — Mon, 14 Mar 2011 19:14:35 +0000

It is becoming common knowledge that our bone strength decreases as we age. Typically the condition is known as osteoporosis, alias thinning of the bones. Older people with osteoporosis commonly suffer hip wrist and spinal fractures. We are discussing the spinal fractures in this blog, prevention and treatment of other fractures at another time.

The vertbral bodies are shaped like short cylinders and they support the body against gravity during any weight bearing activity. When the vertebral bodies loose strength and become osteoporotic even small trauma can cause a compression fracture in which the front of the bone is pushed down and the posterior (back ) part is intact. This causes severe pain but usually does not cause any nerve problems. Treatment used to consist of bedrest, bracing and time.

There are new treatment options including calcitonin injections and bone cement (vertebroplasty and kyphoplasty) as well as the standard pain medications and anti ostroporosis drugs. Recent articles from the AAOS have explored the most effective treatment protocols. The results are powerful. In a neurologically intact patient symptomatic treatment with rest, time pain medications has been augmented with calcitonin a hormone which helps builds bones. Usually this should be done for one month before it is deemed a failure. The next level of treatment is flet to be kyphoplasty a minimally invasive treatment in which the fracture is put back into normal shape with a balloon like device and then fixed with bone cement to stabilize the bone in the corrected position. Vertebroplasty ( a smilar treatment without the balloon correction) does not work as well. There is no invasive surgery indicated in the neurologically intact patient

In the long run drugs to prevent further osteoporosis are needed of caurse as well as instruction in body mechanics to prevent further fractures

more on bone grafts: allografts

dlovejoy4 — Tue, 01 Feb 2011 22:04:42 +0000

Allograft bone is bone taken from cadaver, cleaned and sterilized.. It can come fresh, with intact cartilage, but more commonly it is dried. The dried allograft can come as crushed cancellus bone or as structural bone using the cortex. Obviously, allograft bone does not contain the usual osteoprogenitor cells and the bone morphogenic protein contained in fresh autograft bone. On the other hand, there is no pain or risk of infection at the donor site. studies have shown that allograft bone used in the cervical, lumbar and dorsal spine as well as in the feet and ankles is very effective in creating a fusion. Again it is obvious that proper tissue handling and testing techniques must be used to protect the recipient.

As a rule I only use sources for allograft bone who have been proven to a tear to the strictest standards. in my opinion allograft bone is more for the patient, and the results from the use of allograft bone are just as good as for autograft.. it is important however that the patient be informed of the risks benefits and alternatives of allograft versus autograft bone graft.

The use of fresh allograft allows grafting of cartilage cells which are able to survive the harvest storage and transplant process . This is a technical process which is valuable in some specific surgical situations, and has to be picked for selective cases

Bone Grafts I

dlovejoy4 — Tue, 21 Dec 2010 20:19:45 +0000

Bone grafts have been used in orthopaedics for many years. They have become standard treatment in certain kinds of fractures, for treatment of non union of fractures and in facilitating fusions. Traditionally bone grafts have been taken from the pelvis leg or arm of the patient and transferred after harvest to the area of the body which needed the bone for healing. The transferred bone would then incorporate into the surgical site and hopefully lead to increased healing.

There are two type of bone graft available inthe human body. Cortical bone is the outside of the bones. Cortical bone is dense, hard and is a good structural graft. Cancellous bone is in the inside of the bones and is not a dense or strong but it contains blood marrow cells which can provide bone progenitor cells and hormones cusch as bone morphogenic protein which can stimualte bone growth. Each type has the ability to act as a scaffold for further bone growth. The choice of the type of bone depends on the mechanical and biologic situation and sometimes both are needed. Usually bone graft is taken from the iliac crest (the pelvis) a good source of either cortical or cancellous bone.. Both arms or legs could be used however depending on the amount of bone needed and the ultimate destination of the graft. Often a small graft from the forearm can suffice for a graft to the wrist, for example.

Next issue allograft vs autograft vs artificial graft substances

Achilles Tendon Ruptures Redux

dlovejoy4 — Mon, 13 Dec 2010 19:12:33 +0000

A recent article in the Journal of Bone and Joint Surgery (our main academic journal) recently confirmed our discussion about non operative treatment of Achilles tendon ruptures. That is, many if not all ruptures of the Achilles tendon can be treated without surgery. The technique involves early immobilization in a cast with the foot plantar flexed (pointed downward), followed by early weight-bearing in a brace and controlled motion. This techniques opposed the ruptured ends of the tendon to each other by plantarflexion and then protected weight-bearing allowed earlier healing.

The results confirmed the results of earlier European studies and also found a low re-rupture rate in those treated without surgery, and a higher complication rate (mostly wound issues ) in those treated surgically. It would appear that either operative or non operative treatment works by putting the ends of the tendon together and allowing them to heal in a protected environment. This article reaffirms the soundness of either operative or non operative care if done in a well thought our and executed manner.

Tendonitis/Tendonosis

dlovejoy4 — Tue, 07 Dec 2010 16:54:30 +0000

Every one has had pain in a tendon at one time or another, either spontaneously or from an injury. Occasionally this pain becomes chronic and severe, and we will discuss this today with an emphasis on the achilles tendon. The achilles tendon connects the gastrocnemius muscle of the calf to the heel bone, and we have discussed ruputres before. Often the tendon becomes swollen and tender over the subcutaneous area just above the heel and every step hurts.

Initial treatment includes ice , non steroidal anti-inflammatory medications and stretching. This treatment plan often works and the pain resolves. In some cases, pain and swelling pesist and there is a fusiform swelling over the tendon. This chronic treatement resistant condition is called tendonosis.

Tendonosis is pathologically characterized by neovasculariztion (new blood vessels) and a poor healing response and this is thought to be the source of the pain. This phenomenon can be seen in other tendons as well. The treatment options are multiple but the best option is not known. Cortisone injections rarely work and particularly in the achilles tendon may lead to rupture. High and low energy shock waves have been tried (they are thought to change the healing response) and the results are poor for low energy and mixed for high energy shock waves. Nitrous oxide patches may work, but here is no evidence that plyotherapy (saline injections ) work. Surgery with either major stripping of the tendon lining, or percutaneous longitudinal incisions has also been used with mixed results

Ths best advice is to work through the exercise and ice and massage regime and gradually use other modalities. In any case there is no quick, 100% reliable treatment and one can expect at least a six month course.

surgical treatment of Achilles tendon ruptures

dlovejoy4 — Mon, 15 Nov 2010 15:26:40 +0000

Surgical treatment of Achilles tendon ruptures has been the main stay of treatment for many years. Years ago the tendon was approached through a long posterior incision, repair was made with large sutures and a long leg cast applied. More recently smaller incisions have been used with careful preservation of the skin, limited retraction of the skin and a careful repair of the peritenon, and a short leg cast used. The biggest risk of these surgeries has been infection, likely because of the poor vascular supply of the area.
As result of these complications, which can be devastating, less invasive techniques using minimal incisions and percutaneous suturing have been developed. In the absence of complications such as infection, the results of both types of techniques have been very gratifying. Postoperatively the patient is placed in a rigid cast for 2-3 weeks nonweightbearing. Partial weightbearing with a plantar flexion cast or brace and active dorsiflexion with passive plantarflexion is started. The full time for rehabilitation can be 3-6 months for a normal person but return to sports can take as long as one year. As always, diabetes and smoking increase the risk of complications and failure.
Neglected Achilles tendon tears, those over a few weeks or recurrent tears can require more complex surgery such as tenon turn downs, allografts or flexor hallusis transfers, more about the last later.
Overall the surgical results are excellent with a low rerupture rate, but an increased infection and complication rate which has to be recognized before surgery is undertaken.

Achilles tendon ruptures non operative

dlovejoy4 — Thu, 11 Nov 2010 18:26:57 +0000

Achilles tendon ruptures are seen in both athletic and sedentary patients. the Achilles tendon connects the gastrocnemius and soleus muscles to the heel. ruptures usually occur when there is an acute pushoff or plantar flexion force against a solid object such as the ground. There is usually no warning or prodrome. The patients often state that it feels as if someone hit them with a baseball bat just above the ankle.

Typically, the rupture happens 2 inches or so above the heel bone, In area of poor blood vessel supply. the patient is unable to walk as they cannot push off strongly with the foot and cannot rise on her toes. Often the injury is mistaken for an ankle sprain and can occasionally be neglected for prolonged periods time.
The treatment options include casting and surgery. casting involves a short-leg cast with the toes pointed downwards and crutches for some 4-6 weeks followed by a careful program of rehabilitation. Nonoperative treatment can be successful in most cases. The advantage of nonoperative treatment is that surgery with the risk of anesthetic and infection can be avoided. The risk of this however is a markedly increased rerupture rate and difficulty obtaining the correct tendon lengths. this is not a problem in a sedentary individual, but most athletic patient’s choose an operative intervention.
the next article will discuss options of operative treatment.

Non Operative Treatment of Knee Arthritis

dlovejoy4 — Tue, 02 Nov 2010 20:20:29 +0000

A recent AAOS consensus meeting about the non operative treatment of knee arthritis has brought us some simple if discouraging news. This panel of surgeons reviewed the available high quality literature to assess the truly useful non operative treatments, in order to see what we as surgeons can do for folks who do not want or are not ready for joint replacement surgery.

Not surprisingly, the most effective non operative treatment is weight loss. Obese patients place an increased load on the knees and the load leads to increased arthritis, pain and disability (without even assessing the other effects of obesity. The data show that losing weight can increase function and decrease pain for a majority of patients with knee arthritis. It does not cure the condition but makes it more bearable.

Exercise can help as well , but not all exercise. Running , jogging and high impact aerobics condition the body but do not help the knee. Low impact exercise such as swimming, walking in water and walking can be helpful particularly when linked with exercise.

Non steroidal anti-inflammatories may help but there is no evidence that they can effect a long-term cure. They are worth trying, but there are no guarantees. Similarly, cortisone and hyaluronic acid injections can be helpful in the short term but rarely provide a long term cure. Again worth trying as they are low risk, but limited long term effectiveness.

Finally there is no convincing evidence that braces, glucosamine, therapy and acupuncture provide more than casual relief. These trials were controlled with placebos and seem to indicate that some people get relief from these modalities, but not enough to recommend them as treatment.

So, as I said not really surprising but sobering

hot weather and orthopedic surgery

dlovejoy4 — Thu, 08 Jul 2010 19:10:20 +0000

The current heatwave dominating East Coast leads to many requests from parewnts and children for water proof casts and from adults who want to know when they can get back into the water after surgery.

There is no good way to wear a cast in the water without protection. Plaster casts get soggy and fall off, fiberglass casts get wet and uncomfortable and take forever to dry, and even the “waterproof “gortex cast liners can cause skin irritation. Sitting in front of an air conditioner can help, but the issue of swimming bathing and showering remains an issue.

The only asnwer so far is a cast cover either commercial or homemade. These are essentially large plastic bags with a diaphragm or tape at the top which keeps out water. Regretably they are often not perfect and certainly will not stand up to repeated underwater stress, they work for showering and sitting in the water without submersing the limb. Once the cast gets wet, the only option is to use a blow dryer on cool, this can dry the cast out.

Surgical wounds are a different matter and once the wounds are healed , it is safe to go in the water with care, but stressing the wound and muscles has to be avoided.

The beach has its own problems with sand and dirt in the cast and in wounds and extreme caution has to be used.

I wish there wer a miracle cure, but kids and surgical patients must be cautious or will make their issues worse