Michael Mulligan

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.

Diabetes mellitus: musculoskeletal manifestations and perioperative considerations for the orthopaedic surgeon.

Diabetes mellitus is a disease of uncontrolled hyperglycemia. Despite a more sophisticated understanding of the pathophysiology of diabetes mellitus and despite pharmacologic advancements that enable better glycemic control, the prevalence of this disease and its devastating sequelae continue to rise. The adverse effects of diabetes on the nervous, vascular, and immune systems render the musculoskeletal system vulnerable to considerable damage. Foot involvement has traditionally been thought of as the most severe and frequently encountered orthopaedic consequence. However, the upper extremity, spine, and muscles are also commonly affected. Orthopaedic surgeons are more involved than ever in the care of patients with diabetes mellitus, and they play a vital role in the multidisciplinary approach used to treat these patients. As a result, surgeons must have a comprehensive understanding of the musculoskeletal manifestations and perioperative considerations of diabetes in order to most effectively care for patients with diabetes mellitus.

Assessment of orthopaedic literacy in an urban emergency department: pilot results of the literacy in musculoskeletal problems (LiMP) project

Background:Health literacy is considered the single best predictor of an individual’s health status. However, it often is difficult to assess. As such, our group developed the Literacy in Musculoskeletal Problems (LiMP) questionnaire, a musculoskeletal-specific literacy assessment tool. We hypothesized that the degree of inadequate musculoskeletal health literacy would be higher than the rate of inadequate general healthy literacy, as assessed through the Newest Vital Sign (NVS). Methods:Each of the 65 study participants completed a demographic questionnaire, the NVS and the LiMP survey. The NVS and LiMP scores were assessed using contingency table analysis. Categorical outcome variables as a function of demographic parameters also were compared using &khgr;2 tests. Results:More subjects were found to have inadequate musculoskeletal literacy (60%) as compared with general health literacy (48%). Contingency table analysis showed that at LiMP scores of less than 6, the sensitivity and specificity (0.74 and 0.59, respectively) were optimized for predicting limited literacy, as defined by an NVS score of 3 or less. A significantly higher rate of adequate musculoskeletal literacy was observed in Caucasian patients and those who had previously seen a physician for a musculoskeletal complaint. Conclusions:The LiMP’s sensitivity and reliability is in line with prior work on disease and specialty-specific literacy, making it a valid and reliable musculoskeletal literacy assessment instrument. It is only with the ability to identify those lacking the skills crucial to making informed decisions regarding their musculoskeletal health that we can accurately target education campaigns, an approach that will ultimately enhance physician-patient interactions and improve clinical outcomes.

Volar Ligament Repair for Radiocarpal Fracture-dislocation

Radiocarpal fracture-dislocations are uncommon injuries, comprising a spectrum of trauma to the capsuloligamentous complex and osseous structures of the radiocarpal joint along with the adjacent structures. Management guidelines are derived from limited case series and expert opinions. An understanding of the relevant anatomy suggests that restoration of an anatomically reduced joint in conjunction with repair or reconstruction of the osseous and soft tissue structures optimizes outcome. Special consideration should be given to repair of the radial styloid, intercarpal ligaments, and radiocarpal capsuloligamentous complex. The authors report 2 patients with radiocarpal fracture-dislocations in which reduction and stabilization of the carpus was achieved using suture anchor fixation of the volar extrinsic radiocarpal ligaments.

Musculoskeletal Health Literacy in Patients With Foot and Ankle Injuries A Cross-Sectional Survey of Comprehension

Purpose. Approximately 33% of Americans have inadequate health literacy, which is associated with decreased medical knowledge, increased hospitalization and use of emergency care, and worse control of diseases. In this study, the Literacy in Musculoskeletal Problems (LiMP) questionnaire was used to evaluate the prevalence of limited musculoskeletal literacy in patients presenting to the emergency department (ED) with foot and ankle–related complaints, as these individuals may be at increased risk for inferior outcomes. Methods. In this cross-sectional study, individuals ≥18 years of age presenting with foot and ankle–related complaints to the ED were invited to participate. Participants completed a demographic survey and the LiMP questionnaire, with scores ≥6 indicative of adequate musculoskeletal literacy. The prevalence of adequate health literacy and the influence of demographic parameters was assessed. P values <.05 were considered significant. Results. The mean LiMP score was 5 ± 2.06. Limited musculoskeletal health literacy was seen in 32% of participants (18/56). Although gender (male), a current or prior employment in a health care field, and having previously seen a physician for a musculoskeletal complaint correlated with higher literacy rates, these values did not reach statistical significance (P > .05). However, Caucasians and those with higher levels of education (equal to or more than college) were significantly more likely to possess adequate literacy (P = .008, P = .04, respectively). Conclusions. Approximately one third of patients presenting to the ED with foot and ankle–related complaints have limited musculoskeletal literacy and may lack the necessary skills required for making informed decisions regarding their care. This is concerning and has tremendous socioeconomic implications, as more than 23 000 people per day require medical care for ankle sprains in the United States, with average treatment costs for this injury in the ED setting estimated at

Third Place: Do rates and risk factors for limited musculoskeletal health literacy differ between patients in the emergency department and patients in an outpatient orthopaedic surgery practice?

1498. Identification of those most at risk is thus crucial and will facilitate the development of interventions geared toward those most vulnerable. Levels of Evidence: Prognostic, Level IV study

Minor traumatic brain injury: a primer for the orthopaedic surgeon.

Background:Inadequate health literacy has been correlated with poorer health and worse outcomes in musculoskeletal health. It is therefore helpful to identify those with deficiencies to obtain better results. Through the use of a previously developed Literacy in Musculoskeletal Problems (LiMP) questionnaire, the prevalence of musculoskeletal literacy was compared between patients in an emergency department (ED) and an outpatient orthopaedic practice. Methods:In this cross-sectional study, 130 participants completed a demographic survey and the LiMP questionnaire. A t-test was used to compare the prevalence of inadequate literacy in the ED and outpatient settings. A x2 test determined the influence of demographic parameters. Results:The overall prevalence of inadequate musculoskeletal literacy was 45%. Outpatients were significantly more likely to possess adequate literacy as compared with ED subjects (P<0.05). In both groups, patients who had previously seen a physician for a musculoskeletal complaint were significantly more likely to have adequate musculoskeletal literacy (P<0.05). In the ED, Caucasians also were significantly more likely to have adequate musculoskeletal literacy (P<0.05) compared with other ethnicities. Conclusions:The prevalence of inadequate musculoskeletal literacy is concerning as is the discrepancy in literacy observed between ED and outpatient participants. Future interventions and educational campaigns must focus on the demographics most at-risk, such as those identified in this study.

Financial impact of total hip arthroplasty: a comparison of anterior versus posterior surgical approaches

Abstract Minor traumatic brain injury (mTBI) is a major public health problem. The Centers for Disease Control and Prevention and the National Center for Injury Prevention and Control label it a “silent epidemic.” Subtle signs and symptoms of mTBI, including headache, fatigue, and memory loss, are often seen in conjunction with musculoskeletal trauma. Although sometimes evident immediately, mTBI may not manifest until patients return to work and their personal lives. In the patient with acute concurrent mTBI, skeletal management must be based on either a period of observation to rule out evolving neurologic symptoms or, when warranted, the recommendations of a neurosurgeon. Such input is particularly important when mTBI is associated with a prolonged loss of consciousness or posttraumatic amnesia. In the outpatient setting, when concern for mTBI exists weeks after an injury, familiarity with and referral to locally available mTBI specialists and programs can facilitate proper care. Armed with this knowledge, the orthopaedic surgeon has an opportunity to positively influence outcomes and help provide crucial care that extends beyond the management of musculoskeletal injuries.

A Cross-Sectional Study of Musculoskeletal Health Literacy in Patients With Carpal Tunnel Syndrome.

Background Compared to the posterior approach, the anterior approach to total hip arthroplasty (THA) offers the potential for an accelerated recovery secondary to less dissection and therefore less pain in the immediate postoperative period. This offers potential financial benefit through a reduction in length of stay. This study retrospectively reviewed 98 anterior approach and 69 posterior approach THA cases (N = 167) to compare perioperative outcomes and cost-effectiveness. Methods Patients who underwent anterior approach THA were discharged sooner than those who underwent posterior approach THA. Results The anterior approach was also less expensive per patient than the posterior approach. Overall, differences in perioperative outcomes between these approaches to THA are less robust than previously reported. There is a significant difference in operative cost between these surgical approaches. Conclusions Although there are many sources for this difference in cost, the predominant contributor is surgeon implant preference.

Intramedullary Nailing in a Tibial Shaft Fracture With Distal Articular Extension

Background: Approximately 33% of Americans have inadequate health literacy, which is associated with infrequent use of preventative services, increased hospitalization and use of emergency care, and worse control of chronic diseases. In this study, the Literacy in Musculoskeletal Problems (LiMP) questionnaire was used to evaluate the prevalence of limited musculoskeletal literacy in patients undergoing carpal tunnel release (CTR), as these individuals may be at increased risk of inferior outcomes. Methods: This cross-sectional study included individuals older than or equal to 18 years of age who were scheduled for elective CTR. Participants completed a demographic survey and the LiMP questionnaire during their preoperative office visit. The prevalence of limited health literacy was determined, with chi-square analysis used to determine the influence of demographic parameters. Results: The mean LiMP score was 6 ± 1.40. Limited musculoskeletal literacy was seen in 34% of participants (22/65). Analysis identified race (Caucasian), gender (female), higher education levels (≥college), current or prior employment in a health care field, and a prior physician visit for a non–carpal tunnel musculoskeletal complaint as being associated with higher literacy rates. Conclusions: Approximately one-third of patients scheduled for elective CTR have limited musculoskeletal literacy and may lack the necessary skills required for making informed decisions regarding their care. This is concerning, as CTR is performed in the United States on roughly 500 000 individuals annually, at an estimated cost of 2 billion dollars. The identification of those most at risk is thus crucial, and will facilitate the development of education campaigns and interventions geared toward those who are most vulnerable.