Controversies in Treatment of Achilles Tendon Ruptures

Achilles tendon ruptures are very common sports injuries.   Many years ago, these were treated without surgery, but muscular weakness and a high risk of re-rupture were common problems.  Over the past 10-15 years, the majority of orthopedists have advocated repair.  Repair clearly decreases the risk of re-rupture, but muscular weakness remains an issue, and there are risks of infection, wound healing complications, and nerve damage.

In the past few years, the controversy as to whether surgical or nonsurgical treatment is preferred has resurfaced.  Some recent studies suggest that when the same accelerated rehab program is used, the outcomes for surgery or nonoperative treatment are much more similar than in the “old days”.  We used to immobilize patients longer in a boot or cast, whether or not we did surgery.  Accelerated rehab somewhat decreases the difference in outcomes, but there is still a somewhat higher risk of re-rupture and more muscular weakness without surgery.

This article  found that nonsurgical treatment of achilles tendon ruptures results in significantly more chronic muscular atrophy than surgery.  In addition, without surgery, the tendon heals nearly 2cm longer (stretched).  I’ve always been a strong proponent of surgical repair for achilles tendon rupture.  The study I’ve cited here is just one data point, but in combination with the well established body of research and my own clinical experience, it strongly reinforces my recommendation for surgical repair of these injuries for the vast majority of my patients.

Operation Rainbow

Last week I was priveleged to join Operation Rainbow on an orthopedic mission to Guatemala.  I’ve been familiar with their work for a number of years, as some of my San Francisco colleagues have been on trips with them.  This inspiring group does great work taking care of patients and educating doctors in developing countries.  Last week we saw 440 patients and performed 65 surgeries in Huehuetanago, Guatemala.  This video shows the incredible work Operation Rainbow does year after year.  Please click, it’s worth watching.

There’s No Place Like Home

As this recent article from the New York Times points out, the rehab facility (or hospital) is not the best place to recover from joint replacement surgery. 

You want to get out of the hospital as soon as you are stable and get home where (1) you won’t be exposed to a lot of sick people and (2) you’ll have a lot of incentives to keep active and move around – there’s a lot more interesting stuff to do at home. 

With modern anesthesia and pain management techniques requiring far less narcotics, people can go home faster feeling better than ever before. If you were living alone before your knee  replacement,you should be able to go right back to that (with some pre-planning of course. Someone will have to walk the dog and do the shopping for a few weeks).  

The majority of patients leave the hospital after a night or two. Some, with the proper support, can safely go home the same day.  The key to great rehab is to get you back to your daily routine ASAP, and build on that. 

Relieving Post Surgical Pain Without Narcotics?

Orthopedic surgery is painful.  There’s just no getting around the basic fact.  A lot of my patients, when they learn they need surgery, are more concerned about the pain, than the details of the actual surgery.  And almost no one really wants to be on narcotics.  Fortunately with multi-modal pain management (using smaller amounts of several medications rather than a whole lot of one) and regional anesthesia (blocking individual nerves and groups of nerves) the need for narcotics is a lot less than it used to be.

Every individual is somewhat unique in how they handle pain, and some of us need more medicine than others.  Some surgeries hurt more than others, too.  Most, but not all, orthopedic procedures will entail taking some amount of a narcotic, such as vicodin, for at least a day or two.  Some may not.  And it’s important to know that there are many strategies we can employ to try to minimize the use of narcotics – important for a lot of my patients who are allergic or just don’t tolerate them well.

I have several protocols that I use for various surgeries to try to make patients comfortable without overmedication.  These include the use of anti-inflammatory medications and milder pain relievers in addition to cold therapy and regional anesthesia.  Each of these approaches can be fine tuned for the individual.  When you are considering surgery, don’t be afraid to ask your surgeon about their plan for your pain relief.  Make sure your surgeon understands your concerns and your previous experience with medications so that together, you and your surgeon can come up with the best plan to keep you comfortable.

In my experience a team based approach allows for the plan best tailored to the individual, and in some cases for small procedures, allows a patient to manage without narcotics when that is their goal.

Shoulder Dislocation and Re-Dislocation

Anterior shoulder dislocation is a common injury, and one that I see frequently in athletes of all ages.  Risks of repeat dislocation depends on many factors, including particularly the injured person’s age, whether the dislocation caused any bony defects, and the size of those defects.  Decision making regarding surgery/no surgery can be difficult in some cases.  When there is bone injury, however, the decision is usually surgery.  The most common bone injury, called the bony Bankart lesion, is a defect in the front of the shoulder socket, (glenoid), that occurs due to the impact of the dislocation/relocation event.  Having this bony injury with a dislocation increases the likelihood of repeat dislocation.  Most of these injuries can be treated with a simple arthroscopic surgery to repair the soft tissue along with the small piece of attached bone.

Larger bone pieces have a higher risk of repeat dislocations, and the larger the defect, the bigger the risk.  For defects that comprise 20-25% of the glenoid socket or more, we would classically perform a reconstruction of the bone defect, which is a more involved procedure and involves larger incisions.  When I was in training, I studied at UC Irvine and the Long Beach VA biomechanics lab, which created an anatomic laboratory model to study shoulder motion and dislocation, I used this excellent model to study the forces involved in dislocating an uninjured versus a repaired shoulder in order to to evaluate repair quality.  The lab continues to do cutting edge work in dynamic modeling of joint motion in the laboratory.  This recent study from my alma matter now suggests that we look at repairing glenoid defects at lower thresholds of around 15% bone loss.

Barefoot Running

Some years after the surge in popularity of barefoot running or running in minimalist shoes, there is enough data for an orthopaedic review article.  The verdict?  A decrease in anterior knee pain (runner’s knee) and a decrease in chronic exertional compartment syndrome.  But, an increase in risk of repetitive stress injuries to the foot and ankle.

Some years ago I saw a rash of stress fractures and posterior tibial tendonitis, around the time barefoot running was gaining in popularity.  Over time that has tapered off, and I’m now seeing the usual mix of anterior knee pain and shin splints along with tendonitis and stress fractures.  The change in injury trends probably relates to adoption of a popular new technique, followed by adaptations, including the use of mimimalist shoe wear rather than running unshodden.  These days I see a lot more runners in “typical” running shoes than the minimalist version, but I do see both.

It’s interesting and frustrating that despite all the effort that has gone into the study of running gait and running injuries over the past 40 years, the incidence of running injuries hasn’t changed.

I’m hoping this article may be of interest to my running patients.  There are many great health benefits to running, but those benefits don’t come without risk.  Any runner who makes a decision to change foot strike should consider those risks particularly in light of any previous history of running injuries, and consider the supervision of a good physical therapist or running coach.

 

NSAIDs and Tendinitis

The New York Times published an article in the past couple of days about NSAIDs and their use to treat tendinitis.  The basic point is, tendinitis really isn’t an “-itis.”  That is, it is not an inflammatory condition but rather one of tissue breakdown and as such, NSAIDs treat only symptoms and are not curative.  In some cases, NSAIDs may impair the healing response.  These are facts that have been well known by doctors for many years, but usually come as a surprise when I explain this to my patients. Take a look at this article.  The facts are correct, and useful information for everyone.  NSAIDs are useful tools, and I do prescribe them a fair amount, but most tendon conditions (short of complete rupture of course) are most definitively addressed by a specific exercise program.

EHR

Electronic Health Records, otherwise known as electronic medical records, have been around for over 20 years now in various forms.  Despite their longevity and growth in implementation in recent years, they have not improved.  They have increased the cost of providing medical care without improving efficiency or, in many instances, patient safety. EHR is a great idea that has been poorly and haphazardly implemented with the main goals of revenue generation for the companies that sell them, and for billing efficiency.  The focus needs to be on patient care and communication – communication between providers, and between patients and their providers.  New technology usually makes our lives easier.  Even those of us who love any tech we can get our hands on, cannot love our EHR’s.  Here are a couple of interesting perspectives on the problem.

http://www.kevinmd.com/blog/2015/12/put-ehrs-back-right-track.html

http://www.usatoday.com/story/news/nation/2015/02/01/backlash-against-electronic-medical-records/21693669/

What’s the solution?  Well, if it was easy, it would have already been done.  But there are good arguments to having one universal system, accessible to all doctors, with individual patient records to be accessible to the doctors designated by those patients.  We already have a nationwide EHR at our VA Medical Centers.  There are barriers and security concerns with a nationwide solution, but huge advantages to think of as well.  Some food for thought as we consider the ongoing changes in our health care systems.

Save My Knees

Many times I have patients come to me with knee pain, and want advice on how to “save” them so they don’t wear out.  Their usual assumption is that minimizing the use of their joints will “save” them or extend their useful life.  While that is probably true of your car tires, it is not true of your cartilage.  While overloading a damaged joint may tend to cause an increase in wear, most people are not in that situation.  Cartilage (the part of your joint that wears down) is a matrix supported by a small number of cells.  That sparse population of cells is tasked with maintaining the bearing surface of the joint, and those cells need to be fed.  Nutrients those cells need exists in your joint fluid, and motion and physiologic loading helps to push those nutrients into the cells that need them.  Bottom line: you must move your joints to keep them healthy.  Minimizing activity or putting off exercise until you lose weight is generally counterproductive and may actually contribute to poorer cartilage health.  Individual situations obviously vary greatly, and so this is not specific advice for any individual.  If you have knee pain please, see your doctor.  There is a lot we can do to help.

Ankle Sprains

Summer is coming fast, and my office is filling up with people with injured ankles. Soccer, trail running, skateboarding. Whatever your sport, the most common ankle injury is a lateral sprain – that is, a sprain of the ligaments on the outside of the ankle. This happens most often with an inversion injury – rolling your ankle. Some sprains may be mild enough to walk off and keep going, but any sprain that results in swelling, bruising, or difficulty walking should be checked out by a professional. It’s not unusual for fractures to occur and be unrecognized until the pain didn’t go away and the athlete shows up for evaluation – weeks later, delaying treatment and healing. Many times, one doctor visit and one or 2 visits to the physical therapist can give you the information and tools you need to recover faster.  Want to read more? Here is some useful information.