The Smoking Gun

Dr Christopher Vertullo
MBBS FRACS F A Orth A
A/Prof Griffith University

A 32-year-old entertainment industry technician presents to an Orthopaedic surgeon for a second opinion. He described an injury after a night of celebration where he fell and suffered a closed transverse fracture to his right patella 9 months prior. He was taken by ambulance to the emergency room of his local public hospital and on the following day open reduction and internal fixation of his fractured patella was undertaken with a tension band. Intraoperative imaging was then commenced and this confirmed that the surgeon had achieved an anatomic reduction of the fracture with a tension band wire. 

The patient was initially managed in a splint, touch weight-bearing on crutches and range of motion exercises were started two weeks later. Initial radiographs at 8 weeks suggested anatomic reduction was maintained. However, at 3 months a delayed union was diagnosed, and at 7 months a non-union was noted, with fixation wire breakage, and displacement of the fracture fragments. The patient also complained of severe pain and stated he is "extremely disappointed" with the care received at the hospital. 

The surgeon noted at the time that the patient was an active smoker consuming 1.5 packets per day since he was 16 years old. 

The outpatient notes from the public hospital contained multiple references to advice that was given to the patient in regards to not smoking peri-operatively, advice that was not followed by the patient.

The surgeon recommended revision fixation with bone grafting; however, only if the patient were to stop smoking. 

Due to recurrent failure to smoking in the past, the patient was referred to a psychologist, and once the smoking cessation was confirmed, the revision surgery was completed successfully.

Take home messages: 

1. Patient's and sometimes medical staff, have a cognitive bias to downplay the effects of smoking on postoperative complications.

2. Smoking increases infection risk, thromboembolism risk and non-union risk by 300-500%

3. Nicotine patches still increase the risk of complications, particularly non-union 

4. Elective surgery should not be undertaken until smoking has ceased

5. Patients who smoke are more at risk of musculoskeletal trauma, and hence complications

6. Many patients require psychological support to alter their behaviour. 

Rotator Cuff Repair Post-Operative Rehabilitation

Dr Terry Hammond
MBBS FRACs Orth

Case:
A 56-year-old man has had a rotator cuff repair. What should be the post-operative rehabilitation?
 
It is extremely important to protect the rotator cuff repair. For the first six weeks there should be no active movement of the shoulder at all. This means the only shoulder exercise should be a "dead arm hang" (see photo). This involves coming out of the sling and hanging the arm vertically down without any active circular pendulum movements. During this period he should come out of the sling to do hand, wrist and elbow exercises. These can be done actively.
 
After six weeks he can come out of the sling and use the arm for gentle day-to-day activities. No resisted movement or activities should be done. He can gradually increase his activities, going back to manual labour between four and six months after surgery depending on how physical his job is.
 
We know from animal studies that it takes six months for the repair to become solid. Therefore I advise no strengthening of the rotator cuff repair until at least six months after surgery. We don't worry too much about stiffness after rotator cuff repairs- we know this always resolves although it can take many months.
 
Physiotherapy protocols are available on my website http://www.terryhammond.com.au/

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Lower/Lumbar Back Pain and Buttock Pain

Dr Dion Lewis
MBBS (hons) BMedSci (hons)

Case:
There are numerous causes for lumbar back pain and buttock pain. It may feel daunting to treat patients with these conditions. Many have already suffered through long periods of pain with no relief from medical management and numerous other physical and alternative therapies. It is important, therefore, to thoroughly examine and investigate these patients, attempt to locate the anatomical structure or structures causing the pain and then target a treatment plan accordingly. The following examples illustrate the diversity of pathologies found in clinical practice and some of the treatment modalities used to treat these conditions.

1. Patient presents with pain radiating from the lower back all the way down to the foot. Clinical examination reveals L5 weakness and sensory reduction. MRI/CT confirms L5 nerve root compression secondary to right paracentral disc prolapse. L5 nerve root corticosteroid injection may successfully treat this pain.

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2. Patient presents with lumbar back pain and no abnormality on lower limb neurological examination. MRI/CT shows a non-neurocompressive disc prolapse at L4/5. NSAIDs and physiotherapy have not provided relief. An epidural corticosteroid injection may successfully relieve this pain.
3. A patient presents with lumbar back pain with no radiation down either lower limb. MRI/CT shows multi-level facet joint arthropathy bilaterally. Bone scan with SPECT is performed and shows increased activity at the left L3/4 and L4/5 facet joints. Facet joint corticosteroid injection provides initial relief but pain returns. The patient is subsequently referred for median branch block/radiofrequency neurotomy which provides prolonged pain relief.

4. A patient presents with right buttock pain. Lumbosacral and SIJ MRI shows no obvious cause. Clinical examination is suggestive of SIJ dysfunction. Diagnostic local anaesthetic injection into both the membranous and synovial portions of the SIJ confirms origin of pain is from SIJ. Corticosteroid injection, prolotherapy, PRP or radiofrequency neurotomy could be used to treat this pain.
5. A patient presents with morning pain across the buttock and lower back that sometimes warms up by lunchtime and is sometimes there all day. The pain responds to NSAIDs temporarily. Inflammatory markers are elevated, the patient is HLAB27 positive and there are signs of sacroiliitis on MRI of the SIJs. Use of NSAIDs if not contraindicated and referral to a rheumatologist is warranted.

Posterior Shoulder Dislocation

Dr Terry Hammond

MBBS FRACS Orth

 

Case:

A 46-year-old lady presents with a painful shoulder following a fall. She was seen at a small regional hospital and the only x-ray obtained was an AP, which the medical officer thought was normal.

 

She re-presented at two weeks with ongoing pain and restricted movement in her shoulder. Examination findings confirmed a significant lack of external rotation to 5° on the affected side compared with 60° on the unaffected side. A new set of x-rays including a lateral view was obtained, these are seen below.

 

Left hand x-ray: AP view showing the humeral head rotated and overlapping the glenoid. However, it is very easy to misinterpret this as showing a normal shoulder.

 

Central x-ray: This x-ray shows the lateral view of the shoulder.

 

Right-hand x-ray: Same lateral x-ray as the central image. I have outlined the humeral head with a black circle and the glenoid with a red circle. You can see a posterior dislocation of the humeral head. Again it is a subtle finding and easily missed!!

 

A posterior shoulder dislocation was diagnosed. The shoulder was reduced and the patient was treated with 6 weeks of external rotation splintage. Luckily enough a good result was achieved.

 

This case illustrates how easy it is to miss a posterior shoulder dislocation. It is therefore very important to examine all patients who have had a fall even if x-rays appear normal. This is especially important in older patients who may not complain of a great deal of pain - especially if they have dementia. A history of ongoing pain and particularly a lack of external rotation should alert you to the possibility of a posterior dislocation. Lateral and axillary x-rays are vital and need to be reviewed very carefully. If there is any question a CT scan should be ordered. Treatment is usually non-operative and may involve use of external rotation splintage. Careful monitoring must be performed during the recovery period to ensure no further dislocation occurs. A referral to an orthopaedic surgeon is usually required.

Treatment of “Tennis Elbow” (Common Extensor Origin Tendinopathy)

Dr Dion Lewis

MBBS (hons) BMedSci (hons)

 

Case 1: A 41 year old bricklayer is referred via his GP with tennis elbow after failure to respond to treatment with a tennis elbow brace and corticosteroid injection. He initially improved following the injection, but after a few weeks his pain started to return. He had seen a physiotherapist when he first developed pain a few months prior who tried some soft tissue therapies which did not help. The Ultra Sound shows moderate tendinopathy in the common extensor origin with neovascularity but no evidence of tear. After initiation of a tendon loading program with a new physiotherapist and some basic modifications at work, he gradually improved over the next few months without the need for further injectable therapies.

 

Case 2: A 50 year old landscaper was referred with tennis elbow that had persisted for nearly 2 years. Despite a few periods of time off work, 3 corticosteroid injections and intensive rehabilitation with a good physiotherapist who had provided an appropriate tendon loading program, he was still experiencing difficulties. Ultra Sound and MRI showed high grade common extensor origin tendinopathy with an intrasubstance split tear. A surgeon had suggested he may benefit from operative management, but the patient was not keen to pursue surgery at this stage. Two platelet rich plasma injections were performed under Ultra Sound guidance directly into the intrasubstance tear whilst the patient continued his rehabilitation program. With careful guidance, 3 months later the patient was pain free.

 

Like all tendinopathies, tennis elbow can be difficult to treat. As knowledge surrounding the pathophysiology of tendinopathies has expanded, there is an increasing shift away from rest and corticosteroid injection to controlled tendon loading and activity modification. These days’ corticosteroid injections are generally utilised as a means of reducing pain to enable maintenance of an appropriate tendon loading program. Platelet rich plasma also has a role in selected patients, particularly those with more advanced tendinopathy, tendinopathy that has failed to respond to apparently adequate and appropriate rehabilitation or tendinopathy with intrasubstance tendon tears.

Stem Cells Gone Wrong

Dr Christopher Vertullo MBBS FRACS FAOrthA

 

A 64 year old male presents to the Emergency department on a Sunday morning. He is an obese diabetic who describes himself as an occasional smoker. In his 20’s he underwent an open Lateral Meniscectomy and now has severe lateral compartment osteoarthritis. His BMI is 38. Two years prior he was seen by an orthopaedic surgeon and was recommended to lose weight, take improved analgesia and exercise. He was advised the knee replacement was likely, but was told that he really should maximise his non-operative options. 

 

Earlier this year he attended a stem cell clinic in Melbourne, had liposuction, and the fractionated adipose Pericytes were then injected into both of knees as “stem cell” therapy. Some of the Pericytes were then frozen. Due to ongoing pain he went back 5 days ago and had more of the now defrosted Pericytes injected into both of his knees. On Friday he noted increasing pain and swelling in the right knee. On Saturday he saw his GP who diagnosed a possible septic right knee and prescribed oral Cefuroxime. His GP suggested if it didn’t settle, he should attend the Emergency Department. Over the next 24 hours, his knee pain worsened, he developed low-grade fevers and a increasing effusion. 

 

On examination in the Emergency Department, he had a low-grade temperature of 38.4 degrees Celsius and a moderate effusion. His CRP was 87, knee synovial fluid white cell count was 13,600 and he had a mild neutrophilia. He denied a history of gout, but gout crystal was visible on microscopy. No bacteria were visible and the fluid was cultured, but culture results will take 2- 7 days. 

 

What is the diagnosis? 

 

It could be either an acute attack of gout on a background of chronic gout, or a septic knee. Both could have occurred from the injection. The rate of infection is quite low after knee injection, but it remains the most common cause of a septic native knee joint. Because he was started on antibiotics prior to a synovial specimen being taken, he could have a culture negative infection. Bacteria are rarely visible in septic synovial fluid. 

 

What is the management? 

 

Because of the high CRP and synovial cell count, a presumptive diagnosis of sepsis was made. The patient was taken to the Operating Theatre and an arthroscopic lavage and synovectomy was performed. Severe synovitis was noted and severe osteoarthritis in the lateral compartment. The synovial fluid was very turbid with gout crystals visible throughout the knee. Intravenous broad-spectrum antibiotics were commenced and the patient was kept in hospital for 1 week. No culture had occurred by day 7. RNA testing of the tissue biopsy was undertaken, but this was equivocal. The patient made a slow recovery over the next weeks, with resolution of the pain and swelling. Oral broad-spectrum antibiotics were continued for 4 weeks, 

 

Total knee replacement was delayed for at least 6 months due to the possible infection in the joint being a contra-indication. 

 

What is the take-home message? 

 

1. Adipose derived stem cells have no current role in the management of Osteoarthritis. No controlled study has shown improved symptoms over placebo.

2. If a possible diagnosis of a septic joint is made, antibiotics must not be commenced until a tissue sample is obtained. 

3. Weight loss, exercise and appropriate analgesia remain the primary management of uncomplicated Osteoarthritis.

Recurrent Shoulder Dislocations and Bony Bankart Lesions

This CT Scan shows a glenoid with the arrow indicating a large bony Bankart lesion.

This CT Scan shows a glenoid with the arrow indicating a large bony Bankart lesion.

By Dr Terry Hammond
MBBS FRACS Orth

A 17 year old boy presents with recurrent shoulder dislocations. His initial injury was a tackle at rugby at the age of 15. He required reduction under sedation in the Emergency Department. Since then he has had 10 further dislocations with two of these occurring in his sleep. The shoulder feels very unstable in full abduction and external rotation with his arm above his head. Clinical examination shows a very unstable shoulder with a positive apprehension test. The CT Scan above quite clearly shows a large bony Bankart lesion.

In patients with recurrent instability it is important to exclude a bony Bankart lesion. This is a fracture of the anterior and inferior aspect of the glenoid. This makes the shoulder highly unstable. If the fragment is large as in this case, an arthroscopic stabilisation has an extremely high rate of failure and a bone graft procedure (such as a Latarjet Procedure) is required. This operation involves performing an osteotomy of the coracoid and then transferring it down to the anterior aspect of the glenoid. It results in a high degree of stability but is obviously a significant operation. Nowadays most patients undergoing surgery for shoulder instability should have a CT Scan to exclude a significant bony Bankart lesion.

Osteoarthritis in the Young Active Male: Knee Preservation or Replacement?

Dr Christopher Vertullo
MBBS FRACS Orth

A 52 year old male carpenter is referred by his GP after failing non-operative rehabilitation with his physio for Left medial knee osteoarthritic pain. His pain on a VAS is between 4-6/10, with a fair score on a Lysholm Knee Score of 60/100.  He stopped running sports 5 years prior, due to medial pain. He stopped pivoting sports over 15 years earlier. At age 25 years he tore his Anterior Cruciate Ligament; however, this was never reconstructed, and he underwent a partial medial meniscectomy 10 years ago.

On examination, his BMI is 27, walks with a varus thrust and his alignment is in varus (bow-legged). His Anterior Cruciate Ligament is incompetent with a Grade III Lachman test and a marked Pivot shift. He indicates medial pain.  He has full range of motion and intact distal pulses.

Plain radiographs show severe medial compartment osteoarthritis, and the MRI confirms a partially absent medial meniscus with extrusion. The Patellofemoral compartment and lateral compartment are normal on MRI. He is in 5 degrees of mechanical axis varus on alignment XRays.

What are his operative options ?
Always using a joint preserving approach in young patients, particularly males, is the ideal approach.  An Arthroscopy is not going to help him as his problem is a combination of medial osteoarthritis and instability. Multiple randomized controlled trials suggest Arthroscopy does not help osteoarthritis symptoms.  A Unicompartmental Replacement (UKR) is contraindicated due to the Anterior Cruciate Ligament deficiency and while some surgeons undertake combined ACLR and UKR, that is a very controversial procedure in any age group, particularly young males.

A Total Knee Replacement would be a possible option, but at 52 he is very young for this. The AOA National Joint Replacement Registry would suggest a male under 55 years would have a failure rate of about 8-10% by the 10th year post implantation. Given his lateral and patellofemoral compartments are well preserved, TKR would be a reasonable option if he was over 60-65, and happy to not run or jump ever again.

A combined High Tibial Osteotomy (HTO) and ACL Reconstruction would offer him the best chance of a stable high functioning knee. This is a technically demanding procedure, requiring at least 6 weeks touch weight bearing after the surgery. Full recovery can take between 6-9 months. Most patients can return to work at between 2 and 6 weeks after the procedure. The correction can be achieved by either doing an opening wedge (as seen in the photo), or a closing wedge. Closing wedge HTO was previously the most common technique; however, the opening wedge is now more common.  Usually some chondral restoration is undertaken, often micro-drilling augmented with PRP.

For more information visit http://www.knee-surgeon.net.au/osteotomy-chondral-restoration/

Acromio-clavicular Joint Pathology Presenting as Recurrent Shoulder Dislocations

Demonstrating the position of the acromio-clavicular joint. Palpation of this joint is important in assessment of possible shoulder dislocations.

Demonstrating the position of the acromio-clavicular joint. Palpation of this joint is important in assessment of possible shoulder dislocations.

By Dr Terry Hammond
MBBS FRACS Orth

Case 1:
A 26 year old man was referred to me with possible shoulder instability having had two apparent shoulder dislocations after falls from his motor-bike. There was no imaging available as he had been seen in remote locations. 

Examination confirmed no shoulder instability but instead showed an injury to the acromio-clavicular joint.
 
Case 2:
A 12 year old girl was referred with a history of apparent atraumatic shoulder instability. She felt her shoulder "dislocate" every time she lifted her arm above her head.
Clinical examination revealed the shoulder was stable but in fact she had instability of the acromio-clavicular joint.
 
These cases demonstrate that a history of possible shoulder dislocation may instead represent acromio-clavicular joint pathology. The most important clinical findings are tenderness over the acromio-clavicular joint or a feeling of instability occurring at the acromio-clavicular joint with arm movements.  The above photo shows the position of the acromio-clavicular joint.  You will note it is very close to the skin and easily palpable.
 
All patients with a possible shoulder dislocation should have their acromio-clavicular joint examined.  This may prevent an incorrect diagnosis of glenohumeral joint dislocation when in fact the acromio-clavicular joint is the source of pathology.

Imaging for Shoulder Problems

This x-ray shows a massive irreparable cuff tear. You will note the humeral head has subluxed superiorly and is eroding the under-surface of the acromion. The cuff tear is always too large to repair in such cases.

This x-ray shows a massive irreparable cuff tear. You will note the humeral head has subluxed superiorly and is eroding the under-surface of the acromion. The cuff tear is always too large to repair in such cases.

Dr Terry Hammond
MBBS FRACS Orth

The simplest, cheapest and most important investigation for a shoulder problem is a plain x-ray.  There are a number of conditions best visualised by this modality.  Osteoarthritis is surprisingly common and a plain x-ray usually provides the diagnosis.  It is also very useful in cases of massive irreparable rotator cuff tears. In this condition the humeral head subluxes superiorly and may even erode the acromion.  If this appearance is seen on a plain x-ray it not only confirms the diagnosis but also confirms that the tear is both longstanding and irreparable.  Plain x-rays also show degenerative conditions of the AC joint and can also show a large spur under the acromion which may erode the rotator cuff.  X-rays are very important in cases of significant trauma. Fractures (such as a fracture of the greater tuberosity) are often undiagnosed unless an x-ray is performed.
 
Ultrasounds have long been used in the diagnosis of shoulder problems.  They are relatively cheap and non-invasive.  However, they are inaccurate unless performed by a experienced musculo-skeletal sonographer.  They probably have a role in screening for a full thickness rotator cuff tear but even then they are often inaccurate. They have a very limited role in investigations of young patients with shoulder problems.
 
Magnetic resonance scans are now the gold standard for shoulder investigation.  They are extremely accurate in diagnosing rotator cuff problems and also show the size of a tear and whether it is repairable.  Magnetic resonance scans are useful for labral tears which are significant in younger patients, particularly those with recurrent instability.  An arthrogram is required in patients who have a suspected labral tear.  MRI scans are particularly useful in serious conditions such as malignancy. 
 
I have developed a protocol for magnetic resonance scanning which I have found particularly useful in diagnosing shoulder problems.  If you are referring a patient my office staff would be happy to arrange scans using this protocol.
 
IN SUMMARY:
The best investigation for a shoulder problem is a plain x-ray.  Ultrasound is probably only useful to screen for a full thickness cuff tear in an older patient.  MRI scanning, often with an arthrogram, is the gold standard.

Atraumatic Knee Pain in the Middle Aged Athlete

Dr Christopher Vertullo
MBBS FRACS Orth

A 62-year-old tennis player presents to you complaining of an atraumatic onset of knee pain over the last few weeks. The pain is associated with a clicking sensation at the front of the knee and is worse after playing. She has never had this type of problem before and is concerned about a meniscal tear. 

When you examine her knee, you note that she has a BMI of 31, a full range of active knee motion, no effusion, some wasting of her quads and some patellofemoral crepitus. The medial side of her knee is not tender. 

Your next management step should be: 

A To arrange an MRI and urgent review

B To reassure that no investigations are needed at this stage as the most likely diagnosis is Patellofemoral Osteoarthritis, and that quadriceps strengthening with her physiotherapist is all that is required.  

C To suggest to stop playing tennis and start some NSAID. 

D To arrange an MRI and urgent orthopaedic surgical review

 

The correct answer is obviously B. An atraumatic onset of knee pain in a middle-aged patient will be degenerative change, in this case of the Patellofemoral joint. The initial management should be to avoid investigations at this stage, lose some weight, strengthen the quadriceps with her physio and consider NSAID prior to playing if no contraindication. 

The patient then returns 6 weeks later, the pain is much better, but she wants to get an MRI to "see what is happening".  

Should you order an MRI ? 

The answer is "not really", as a plain radiograph, particularly looking at the Patellofemoral joint is much more helpful as the initial test. If you initial diagnosis is incorrect, and she has a meniscal tear, arthroscopy will not be indicated, unless her knee is locked or she has a repairable meniscal root tear. The place for MRI in these situations is rather limited, and only when non-operative management has failed or the diagnosis is uncertain from the history and examination. Finally, reassurance that it is safe to continue exercising is vital as it helps the patient lose weight. Patellofeomoral pain really responds to weight loss dramatically. 

Which Investigation for the Painful Knee ?

Dr Christopher Vertullo
MBBS FRACS Orth

It is always difficult knowing which investigation to order when a patient presents with a painful knee. Often the most expensive test is not the best, and in many situations some radiological modalities have no place at all. A 70-year-old male patient presents to you with increasing right medial knee pain and aching. It had an atraumatic onset, and is worse with activity.  He had pain which was 1-3 / 10 previously , but since helping his daughter move house 3 weeks ago it has become much worse, and is interfering with his sleep. You examine him and notice he walks with a limp, has a reduced range of motion to 5- 100 degrees with no effusion. His hip is not stiff to rotation and he has a good distal vascular perfusion to his feet.  He then asks for an MRI, “like all the footballers get”.   

Investigation of atraumatic  onset knee pain should always start with a plain radiograph. A series of four XRs, is the Gold Standard. These include an Erect Antero-Posterior (AP) Radiograph, a Lateral, a Patellofemoral view and an erect flexion AP, known as a Rosenberg. Oblique X-Rays are rarely useful. 

What about the MRI ? Well in these situations, middle-aged or older patients with atraumatic onset of their pain, MRI is only a secondary investigation as the diagnosis is an exacerbation of osteoarthritis and degeneration . In fact, often the XR is all that is needed. The only reason to get an MRI is if the XR shows very little osteoarthritis and the patient fails to settle with a few weeks of rest. In these situations, a stress fracture can present with a similar history but fails to settle with rest. 

The Australian Knee Society recently combined with the Australian MusculoSkeletal Imaging Group to produce a position statement for the investigation of the degenerative knee. It is a handy reference for all musculoskeletal primary care practitioners.