Dean N. Papaliodis

Management of chronic musculoskeletal pain.

&NA; Chronic musculoskeletal pain results from a complex interplay of mechanical, biochemical, psychological, and social factors. Effective management is markedly different from that of acute musculoskeletal pain. Understanding the physiology of pain transmission, modulation, and perception is crucial for effective management. Pharmacologic and nonpharmacologic therapies such as psychotherapy and biofeedback exercises can be used to manage chronic pain. Evidence‐based treatment recommendations have been made for chronic pain conditions frequently encountered by orthopaedic surgeons, including low back, osteoarthritic, posttraumatic, and neuropathic pain. Extended‐release tramadol; select tricyclic antidepressants, serotonin reuptake inhibitors, and anticonvulsants; and topical medications such as lidocaine, diclofenac, and capsaicin are among the most effective treatments. However, drug efficacy varies significantly by indication. Orthopaedic surgeons should be familiar with the widely available safe and effective nonnarcotic options for chronic musculoskeletal pain.

Dedicated orthopaedic operating rooms: beneficial to patients and providers alike.

Objective: Dedicated orthopaedic operating rooms (DOORs) are increasingly popular solutions to reducing after-hours procedures, physician fatigue, and elective schedule disruptions. Although the benefits to surgeons are well understood, there are comparatively few studies that explore the effects of DOORs on patient care. We compared treatments and outcomes for all consecutive patients with femoral neck fractures, 4 years before and 4 years after implementation of a DOOR-based schedule. Design: Retrospective case–control study. Setting: Level 1 academic trauma center. Patients: A total of 111 consecutive trauma patients undergoing surgical management of isolated OTA group 31-B femoral neck fractures. Intervention: Based on individual patient factors and fracture characteristics, patients were managed with either hemiarthroplasty or open reduction internal fixation (ORIF). Main Outcome Measures: Surgical timing, intervention type, perioperative complications, and postoperative length of stay. Results: Retrospective analysis revealed a significant decrease in after-hour surgery (4 PM–7:30 AM) for all femoral neck fractures (66.7%–19.3%; P < 0.001). No significant differences were found between the rates of arthroplasty versus those of open reduction internal fixation. Patients undergoing surgical treatment for femoral neck fractures after DOOR suffered significantly fewer morbidities, including significantly decreased rates of postoperative intensive care unit admissions, stroke, infections, and myocardial infarction or congestive heart failure exacerbations. We also observed a significant decrease in postoperative mortality (5.6% pre-DOOR vs. 0% post-DOOR; P = 0.04). Patients undergoing hemiarthroplasty experienced a significant shorter hospitalization (14.5 days pre-DOOR vs. 9.9 days post-DOOR; P = 0.04). Conclusions: In our experience, a weekday DOOR is closely associated with improvements in both patient safety and outcomes. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The foot and ankle examination.

Most foot and ankle disorders can be diagnosed after a proper history and clinical examination and can be effectively managed in a primary care setting. It is important to assess the entirety of patient disorders that present as they can be multifactorial in cause. A broad differential should include disorders of bones, joints, muscles, neurovasculature, and surrounding soft tissue structures. Physical examination should be thorough and focused on inspection, palpation, range of motion, and appropriate special tests when applicable. This article highlights some of the salient features of the foot and ankle examination and diagnostic considerations.

Computer Assisted Cobb Angle Measurements: A novel algorithm

Background The standard for evaluating scoliosis is PA radiographs using Cobb angle to measure curve magnitude. Newer PACS systems allow easier Cobb angle calculations, but have not improved inter/intra observer precision of measurement. Cobb angle and its progression are important to determine treatment; therefore, angle variability is not optimal. This study seeks to demonstrate that a performance equivalent to that achieved in the manual method is possible using a novel computer algorithm with limited user input. The authors compared Cobb angles from predetermined spinal levels in the average attending score versus the computer assisted approach. Methods Retrospective analysis of PA radiographs from 58 patients previously evaluated for scoliosis was collected. Predesignated spinal levels (e.g., T2-T10) were assigned for different curves and calculated by Cobb method. Four spine surgeons evaluated these Cobb angles. Their average scores were measured and compared to formulated values using the novel computer-based algorithm. Literature reports inter-observer reliability is 6.3-7.2degrees. Limits of accuracy were set at 5 degrees of average orthopedic surgeons’ score. Results The computer-based algorithm calculated Cobb angles within 5 degrees of orthopedic surgeons’ average with a standard deviation of 3.2 degrees. This result was based on a 95% confidence interval with p values <0.001. The computer algorithm was plotted against average angle determined by the surgeons, with individual determinations and linear regression (r2 =0.90). The average difference between surgeons’ measures and computer algorithm was 0.4 degrees(SD= 3.2degrees, n=79). There was a tendency for the computer algorithm program to overestimate the angle at larger angles, but difference was small with r2 = 0.09. Conclusions Our study showed the novel computer based algorithm was an efficient and reliable method to assess scoliotic curvature in the coronal plane with the possibility of expediting clinic visits, ensuring reliability of calculation and decreasing patient exposure to radiation. Level of Evidence: III.

Preliminary trauma radiographs misrepresent pubic diastasis injuries.

The goal of this study was to evaluate the role of portable primary trauma survey radiographs in the evaluation and management of anteroposterior (AP) compression pelvic injuries. A retrospective analysis was conducted at a level I academic trauma center. Twenty-seven adults with AP compressive class pelvic ring injuries who received both portable pelvic radiographs and pelvic computed tomography (CT) imaging in an unbound pelvic state were included. Three orthopedic surgeons performed independent measurements of diastasis on portable pelvic radiographs and coronal pelvic CT reconstructions. Measurement techniques were standardized among observers and were repeated after 8 weeks to assess intraobserver reliability. Nonoperative vs operative treatments were correlated with the initial magnitude of pelvic injury on CT and portable radiographic images. Independent measurements of diastasis on both radiographs and CT scans showed excellent intraobserver reliability (average correlation coefficient, 0.986) and interobserver reliability (average correlation coefficient, 0.979). Compared with diastasis measurements on CT scans, portable pelvic radiographs overestimated diastasis by an average of 49%, or 12.6 mm (P<.0001; 95% confidence interval, 9.6-15.6). Portable pelvic films were less precise than standard pelvic radiographs in measuring the size of femoral head controls (R(2)=0.919 vs 0.759; P=.004). In 12 of the 27 patients evaluated, radiographic indications for operative pelvic fixation were met by portable radiographs but not CT scans, and 11 of these patients ultimately underwent operative fixation. Portable AP pelvic radiographs may distort and exaggerate pelvic bony injuries, especially those involving anterior pelvic structures. Surgeons should use caution when making management decisions based on preliminary portable pelvic radiographs.

Orthopaedic Case of the Month: A 62-year-old Woman With Neck Pain and Neurologic Findings

A 62-year-old woman presented with 3 months of intractable neck pain with recent onset of upper extremity weakness and paresthesias. She reported no fever, weight loss, fatigue, or generalized malaise. She had subtle complaints of hand dexterity loss but said she had no problems with balance, and no bladder or bowel complaints. Analgesics and antispasmodic medications did not relieve her pain. Her medical history was significant for hypertension, hyperlipidemia, diabetes mellitus Type II, multiple sclerosis, depression, anxiety, obesity, and hypothyroidism. There was no history of antecedent trauma, previous rheumatologic phenomena, recurrent infections, or bleeding dyscrasia. There was no family history of cancer or congenital skeletal abnormalities. Review of systems was otherwise negative. On physical examination, the patient was afebrile with normal vital signs. She was oriented to person, time, and environment. The head was normocephalic and sclerae were anicteric. ROM of the neck was normal, and she had no pain with movement of her neck. She had no palpable lymphadenopathy. There was no tenderness to palpation of the posterior shoulder musculature. Cranial nerves II through XII were grossly intact; signs of hypocalcemia including Chvostek’s sign and Trousseau’s signs were not elicited. Abdominal examination was benign without hepatomegaly or splenomegaly. Neurologically, the patient had some mild weakness with wrist extension and finger extension on the left (C 4/5) but an otherwise normal examination with intact sensation and motor function in her lower extremities. Reflexes were brisk and symmetric. Hoffmann’s sign was positive but symmetric suggesting an upper motor neuron lesion, but there was no elicitable clonus. Babinski response was plantar indicating a normal neurologic response in the lower extremities. Laboratory examination showed a white blood cell count of 7.8, hematocrit of 37.3, mean corpuscular volume (MCV) of 84, with a normal differential (54% segmented neutrophils, 9% band neutrophils, 33% lymphocytes), normal chemistries including a serum calcium of 8.9 mg/dL, and an erythrocyte sedimentation rate of 100 mm/hour. We obtained CT scans of the cervical spine (Fig. 1), head, and chest, abdomen, and pelvis, MR images of the spine (Fig. 2), and a whole-body bone scan.