Tennis elbow and golfer’s elbow (lateral and medial epicondylitis) are common afflictions of middle age adults. While associated with various sports activities, these conditions can result from any repetitive activity including those in the workplace. They are less commonly the result of traumatic injury.
While patients many times believe that their symptoms arise from problems of the elbow bones or the elbow joint itself, tennis and golfer’s elbow actually result from problems at the level of the musculo-tendinous attachment of the forearm muscles to the distal humeral (arm) bone. Microscopic tearing of these tendon attachments many times produce the patient’s symptoms
Many physicians believe that both tennis and golfer’s elbow are attritional afflictions, and part of the normal aging process in adults. In this regard, symptoms can resolve on their own over time. However, symptoms in many cases are pronounced and can restrict and impede activities of daily living.
Numerous treatment options are available. Many patients have loss of motion of the elbow and decreased strength, particularly wrist muscle and grip strength. Exercises and/or physical therapy can dramatically improve symptoms. Because epicondylitis is associated with tendon inflammation, oral and topical non steroidal anti-inflammatory agents may be beneficial. Cortisone injections can dramatically improve symptoms, but should not be used repetitively as they may impede the tendon healing process. Bracing supports the inflamed musculature of the forearm and is useful during activities.
Newer therapies include the injection of platelet rich plasma. The goal is to promote healing of the microscopic tendinous tears. These treatments are still being studied and evaluated. Early results are promising but there are at least 5 different variants of injections that are being utilized and none of these therapies is covered by insurance.
Surgery is rarely necessary but generally quite effective, with a recovery period of 2-3 months.
Go Time Ministries is a nonprofit, nondenominational ministry located in the Mon Valley. They operate a community outreach program that administers to youth and adults both locally and abroad. A considerable portion of their activities are designed to meet individuals and community needs.
Go Time has been active in a number of countries including Russia, Haiti and Peru. A recent mission trip to Peru provided portable water filtration systems to an underserved municipality in the capital city of Lima (June 2013).
Three weeks ago Go Time completely its first ever medical mission trip to Lima, Peru. I was proud to be a part of that trip. 21 individuals from the South Hills, including 5 physicians from Jefferson Regional Medical Center participated. We spent 5 days treating patients primarily in the San Martin district of Lima (population approximately 10 million). San Martin has a population of 700,000, one of the largest of Lima’s 43 districts. Many, if not most of these people, especially on the outskirts of the district have never had contact with a physician. We treated and evaluated between 2500-3000 people. Orthopedically, many of these patients were treated for arthritis (medicines, injections), infections and other acquired congenital abnormalities. Referrals were made as appropriate.
Significant support was provided by the mayor of San Marin, Freddy Teimo and numerous municipal employees. We had the benefit of interpreters, as well as local primary care and dentists on site.
Certainly, many of these patients would benefit from orthopedic surgical procedures, but their primary needs are far more basic. In the United States we take for granted our access to health care. Even without health insurance, an emergency room is never that far away. In the Santa Cruz region of San Martin, an emergency room is a minimum of 90 minutes away. Many of these people live as squatters on isolated mountains within the city limits, some as high as 2000 feet. The socialist government provides minimal services for them. Medical consultation/treatment is typically not an option.
That may change. A goal of Go Time Ministries is to secure land and construct a clinic facility in San Martin to better serve the population. This truly was a humbling experience for me.
Total knee replacement surgery has been a highly successful procedure for over 30+ years. 90% of patients who undergo the procedure report improved pain relief, knee function and quality of life.
Long term analysis of knee replacements reveal a tendency toward improved implant survival with better/more accurate alignment (positioning of implants relative to the mechanical weight bearing axis of the leg).
Computer assisted surgery (used during the procedure) for knee replacements has been shown to provide more accurate alignment but is associated with increased set-up and procedure time (approximately extra 15-30 minutes).
Efforts to enhance the negative aspects of computer navigation have led to the development of “patient specific” cutting guides. Detailed magnetic resonance imaging (MRI) of the patients knee is obtained preoperatively along with several images of the hip and the ankle. From these images, computer software is used to create and orient in space virtual 3D models of the femur (thigh bone) and the tibia (leg bone). Appropriate implant sizes are determined with the software, and virtual bony resections are mapped that will accomplish accurate position and alignment. A preoperative plan with visual images is sent to the surgeon for review. Upon approval, actual models of the knee are created as well as disposable custom guides that will fit precisely on the patient’s actual bone (femur and tibia) during surgery to determine accurate placement for the standard bone cutting instruments. In this way, total knee replacement can be performed with custom jigs in truly “patient specific” fashion, achieving optimal alignment. Advantages include less surgical time and blood loss. Also, the technique ensures precise sizing of implants and thus a better fit at surgery. The planning is done prior to the procedure rather than in the operating room.
In addition, surgeons still utilize the same tools in the operating room as with conventional knee replacement surgery. Thus, the same checks and balances to obtain accurate bone resections and prosthetic alignment can be performed. Changes from the preoperative planning have rarely been necessary , with now almost 2 years of experience at Jefferson Regional Medical Center.
www.zimmer.com “the right fit for nearly every knee”
Osteoporosis (porous bones) is a disease in which the bones become thin, or less solid and thus weaker. Thus they are more likely to break (fracture).
The main causes of osteoporosis are aging, heredity (family history), nutrition and lifestyle, medications, and other illnesses.
A gradual loss of bone mass generally begins at age 30-35. This is a fact of life for everyone, but more so for women than men. Factors such as smoking, heavy alcohol intake, steroid use, history of cancer and thyroid problems increase the risk over time.
More than 2 million fractures occur related to osteoporosis each year. Most people are unaware that they have low bone density until a fracture occurs. 80% of osteoporosis occurs in women, 20% in men. More than 1/2 of women over age 50 will break a bone because of osteoporosis in their lifetime (1/4 of all men).
A fracture can be more than just a broken bone. It may be a warning sign that you have osteoporosis. It can be a life changing event. Any bone can break from a fall or injury. In osteoporosis the most common fractures include the spine, wrist and hip. A hip fracture is a particularly serious event. In elderly patients >age 65, 20-25% will die within one year after sustaining a hip fracture. 40% will not return to pre-injury function or activity level. Many of these individuals will require home health or prolonged nursing care aids. A new osteoporosis fracture raises the risk of a subsequent fracture upwards of 5-10 times.
Jefferson Regional Medical Center has implemented the American Orthopaedic Association “Own the Bone” program, an osteoporosis program aimed at identifying, evaluating, educating and treating patients who sustain a fracture secondary to low bone density. The value of the program not only includes identification and treatment of patients with osteoporosis, but also establishes compliance and follow-up through a web based data registry. This is important because presently, only approximately 20% of individuals who sustain an osteoporosis related fracture obtain a bone density evaluation and/or treatment after their injury.
Fractures of the wrist are some of the more common injuries seen in orthopedic clinical practice. They typically occur as a result of falls and thus occur in all age groups. The mechanism of injury can be high energy, such as a fall off of a motorcycle or a sports related injury. Low energy injuries are also common, occurring frequently in elderly individuals after relatively minor slip and fall accidents.
The wrist joint is the junction of the forearm, and its two bones, the radius and the ulna, and the hand. The hand bones (8) are called the carpal bones the radius is the largest bone comprising the wrist and the most frequently injured in falls.
Most distal radius fractures (at the wrist) are minor and can be treated with a cast or splint for 4-6 weeks. Others, however, may result in displacement (separation of pieces), angulations (twisting of pieces) or comminution (fragmentation- multiple pieces). These injuries require more aggressive treatment especially in younger, active individuals. A concern with older individuals, who sustain low energy fractures, is the presence of underlying osteoporosis. A fracture of the wrist is many times one of the first signs of developing osteoporosis , and can increase the risk of subsequent fractures (hip, pelvis eg ) up to 5-10 times.
Numerous treatment options are available. The most simple being a manipulation (setting) of the fracture followed by application of a cast. This may be performed under local or general anesthesia. Other fractures are termed unstable, or unlikely to be maintained in position by a cast. These require stabilization usually with operative fixation, using pins, wires, screws and/or plates. Another indication for surgical treatment is the disruption of the joint surface of the radius (the end of the bone at the wrist joint). Separation or step off of the joint surface greater than 2 millimeters may result in the development of arthritis once the fracture has healed.
One of the most commonly used surgical techniques of fracture reduction and fixation utilizes a small plate, secured to the undersurface of the bone with multiple screws. These are called “locking plates” as the screws lock to the plate and can provide fixation even in very thin, brittle bone. The plates are low profile and placed below the muscles of the wrist on the bone surface. The fracture can be manipulated visually and also with x-ray intraoperatively to gain the desired positioning. The surgery usually takes less than an hour. The skin closure is performed with a subcuticular running stitch (beneath the skin) which requires no suture removal and is quite cosmetic. Post operatively a splint is placed for immobilization and comfort and many times early range of motion can be initiated. Physical therapy is commonly performed. Full recovery averages 3-4 months.
While many older techniques have been equally successful obtaining the desired result of healing, pain relief and return to normal functional activities, volar plating seems to promote a quicker, less painful recovery for distal radius fractures. Rarely do the plates need to be removed.
Follow-up in older individuals involves testing and possibly treatment for underlying osteoporosis.
Helpful websites include;
The hip replacement prosthesis consists of two basic components: the socket and the ball (usually attached to a stem that is impacted into the thigh bone)
These components can be constructed of various types of materials. These materials can be the same or different.
Metal on metal replacement, both for total hips and resurfacing hip procedures consists of a metallic ball articulating with a metal socket. They have been shown to be more durable and potentially last longer than many other implants. Also the ball is typically larger providing increased ROM for activities with much improved stability (decreased dislocation risk). Thus they may be advantageous for younger more active individuals with higher functional demands.
The most important fact, is that the vast majority of patients with these implants have had NO major problems
However, recent information about the wear of certain metal-on-metal devices have raised concerns about their use
When there are problems with these implants, they typically produce increased wear debris, (metal ions secondary to corrosion) which may cause a local soft tissue reaction with pain and swelling, and occasionally loosening of the total hip components. Very rarely, symptoms elsewhere in the body can occur from metal ions in the blood stream.
What is the problem? No one can say with 100% certainty but there are basically 3 areas of concern
- Certain implant designs have been shown to have increased problems and have been withdrawn from the market
- Alignment of the total hip components is important, especially the socket. With a larger metal ball and increased ROM, impingement of components can occur. (e.g. when the shoulder of the femoral stem rubs against the socket, rather than the ball)
- Allergic and hypersensitivity reactions to the metal, implant rejection These are rare
We certainly discuss all of these concerns and joint replacement options prior to any surgical procedure
The FDA statements on these devices can be accessed at: www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalhipImplants.