Developmental Dislocation (Dysplasia) of the Hip (DDH)

Article Featured on AAOS

The hip is a “ball-and-socket” joint. In a normal hip, the ball at the upper end of the thighbone (femur) fits firmly into the socket, which is part of the large pelvis bone. In babies and children with developmental dysplasia (dislocation) of the hip (DDH), the hip joint has not formed normally. The ball is loose in the socket and may be easy to dislocate.Although DDH is most often present at birth, it may also develop during a child’s first year of life. Recent research shows that babies whose legs are swaddled tightly with the hips and knees straight are at a notably higher risk for developing DDH after birth. As swaddling becomes increasingly popular, it is important for parents to learn how to swaddle their infants safely, and to understand that when done improperly, swaddling may lead to problems like DDH.

Description

In all cases of DDH, the socket (acetabulum) is shallow, meaning that the ball of the thighbone (femur) cannot firmly fit into the socket. Sometimes, the ligaments that help to hold the joint in place are stretched. The degree of hip looseness, or instability, varies among children with DDH.

  • Dislocated. In the most severe cases of DDH, the head of the femur is completely out of the socket.
  • Dislocatable. In these cases, the head of the femur lies within the acetabulum, but can easily be pushed out of the socket during a physical examination.
  • Subluxatable. In mild cases of DDH, the head of the femur is simply loose in the socket. During a physical examination, the bone can be moved within the socket, but it will not dislocate.

Illustrations of a normal hip and a dislocated hip

(Left) In a normal hip, the head of the femur fits firmly inside the hip socket. (Right) In severe cases of DDH, the thighbone is completely out of the hip socket (dislocated).

In the United States, approximately 1 to 2 babies per 1,000 are born with DDH. Pediatricians screen for DDH at a newborn’s first examination and at every well-baby checkup thereafter.

Cause

DDH tends to run in families. It can be present in either hip and in any individual. It usually affects the left hip and is predominant in:

  • Girls
  • Firstborn children
  • Babies born in the breech position (especially with feet up by the shoulders). The American Academy of Pediatrics now recommends ultrasound DDH screening of all female breech babies.
  • Family history of DDH (parents or siblings)
  • Oligohydramnios (low levels of amniotic fluid)

Symptoms

Some babies born with a dislocated hip will show no outward signs.

Contact your pediatrician if your baby has:

  • Legs of different lengths
  • Uneven skin folds on the thigh
  • Less mobility or flexibility on one side
  • Limping, toe walking, or a waddling gait

Doctor Examination

In addition to visual clues, your doctor will perform a careful physical examination to check for DDH, such as listening and feeling for “clunks” as the hip is put in different positions. Your doctor will use specific maneuvers to determine if the hip can be dislocated and/or put back into proper position.

During the exam, your doctor will maneuver your baby’s legs and hips in certain ways to detect hip instability.

Newborns identified as at higher risk for DDH are often tested using ultrasound, which can create images of the hip bones. For older infants and children, x-rays of the hip may be taken to provide detailed pictures of the hip joint.

Treatment

When DDH is detected at birth, it can usually be corrected with the use of a harness or brace. If the hip is not dislocated at birth, the condition may not be noticed until the child begins walking. At this time, treatment is more complicated, with less predictable results.

Nonsurgical Treatment

Treatment methods depend on a child’s age.

Newborns. The baby is placed in a soft positioning device, called a Pavlik harness, for 1 to 2 months to keep the thighbone in the socket. This special brace is designed to hold the hip in the proper position while allowing free movement of the legs and easy diaper care. The Pavlik harness helps tighten the ligaments around the hip joint and promotes normal hip socket formation.

Baby in Pavlik harness

Newborns are placed in a Pavlik harness for 1 to 2 months to treat DDH.

Parents play an essential role in ensuring the harness is effective. Your doctor and healthcare team will teach you how to safely perform daily care tasks, such as diapering, bathing, feeding, and dressing.

1 month to 6 months. Similar to newborn treatment, a baby’s thighbone is repositioned in the socket using a harness or similar device. This method is usually successful, even with hips that are initially dislocated.

How long the baby will require the harness varies. It is usually worn full-time for at least 6 weeks, and then part-time for an additional 6 weeks.

If the hip will not stay in position using a harness, your doctor may try an abduction brace made of firmer material that will keep your baby’s legs in position.

In some cases, a closed reduction procedure is required. Your doctor will gently move your baby’s thighbone into proper position, and then apply a body cast (spica cast) to hold the bones in place. This procedure is done while the baby is under anesthesia.

Caring for a baby in a spica cast requires specific instruction. Your doctor and healthcare team will teach you how to perform daily activities, maintain the cast, and identify any problems.

6 months to 2 years. Older babies are also treated with closed reduction and spica casting. In most cases, skin traction may be used for a few weeks prior to repositioning the thighbone. Skin traction prepares the soft tissues around the hip for the change in bone positioning. It may be done at home or in the hospital.

Surgical Treatment

6 months to 2 years. If a closed reduction procedure is not successful in putting the thighbone is proper position, open surgery is necessary. In this procedure, an incision is made at the baby’s hip that allows the surgeon to clearly see the bones and soft tissues.

In some cases, the thighbone will be shortened in order to properly fit the bone into the socket. X-rays are taken during the operation to confirm that the bones are in position. Afterwards, the child is placed in a spica cast to maintain the proper hip position.

Older than 2 years. In some children, the looseness worsens as the child grows and becomes more active. Open surgery is typically necessary to realign the hip. A spica cast is usually applied to maintain the hip in the socket.

Recovery

In many children with DDH, a body cast and/or brace is required to keep the hip bone in the joint during healing. The cast may be needed for 2 to 3 months. Your doctor may change the cast during this time period.

X-rays and other regular follow-up monitoring are needed after DDH treatment until the child’s growth is complete.

Complications

Children treated with spica casting may have a delay in walking. However, when the cast is removed, walking development proceeds normally.

The Pavlik harness and other positioning devices may cause skin irritation around the straps, and a difference in leg length may remain. Growth disturbances of the upper thighbone are rare, but may occur due to a disturbance in the blood supply to the growth area in the thighbone.

Even after proper treatment, a shallow hip socket may still persist, and surgery may be necessary in early childhood to restore the normal anatomy of the hip joint.

Outcomes

If diagnosed early and treated successfully, children are able to develop a normal hip joint and should have no limitation in function. Left untreated, DDH can lead to pain and osteoarthritis by early adulthood. It may produce a difference in leg length or decreased agility.

Even with appropriate treatment, hip deformity and osteoarthritis may develop later in life. This is especially true when treatment begins after the age of 2 years.

Flexible Flatfoot in Children

Flexible Flatfoot in Children

Article Featured on AAOS

When a child with flexible flatfoot stands, the arch of the foot disappears. Upon sitting or when the child is on tiptoes, the arch reappears. Although called “flexible flatfoot,” this condition always affects both feet.

Flexible flatfoot is common in children. While parents often worry that an abnormally low or absent arch in a child’s foot will lead to permanent deformity or disability, most children eventually outgrow flexible flatfoot without developing any problems in adulthood. The condition is usually painless and does not interfere with walking or participation in sports. If your child’s flexible flatfoot does not cause pain or discomfort, no treatment is needed.

Flexible flatfoot

Flexible flatfoot, showing the absence of an arch when standing. The arch reappears when the patient is sitting or on tiptoes.

Description

A flexible flatfoot is considered to be a variation of a normal foot. The muscles and joints of a flexible flatfoot function normally. Most children are born with very little arch in the feet. As they grow and walk, the soft tissues along the bottom of the feet tighten, which gradually shapes the arches of the feet.

Children with flexible flatfoot often do not begin to develop an arch until the age of 5 years or older. Some children never develop an arch. If flexible flatfoot continues into adolescence, a child may experience aching pain along the bottom of the foot. A doctor should be consulted if a child’s flatfeet cause persistent pain.

Doctor Examination

To make the diagnosis, your doctor will examine your child to rule out other types of flatfeet that may require treatment. These include flexible flatfoot with a tight heel cord (Achilles tendon), or rigid flatfoot, which may be a more serious condition.

Tell your doctor if anyone else in the family is flatfooted, as this may be an inherited condition. Your doctor will need to know about any known neurological or muscular disease in your child.

Your doctor will look for patterns of wear on your child’s everyday shoes. He or she may ask your child to sit, stand, raise the toes while standing, and stand on tiptoe. In addition, your doctor will probably examine your child’s heel cord (Achilles tendon) for tightness and may check the bottom of your child’s foot for calluses.

Flexible flatfoot

The arch disappears when standing (left) and reappears when the child is on tiptoes (right)Reproduced from Sullivan JA: Pedatric Flatfoot: Evaluation and Management. J Am Acad Orthop Surg 1999;7:44-53.

Treatment

Nonsurgical Treatment

Treatment for flexible flatfoot is required only if your child is experiencing discomfort from the condition.

Stretching exercises. If your child has activity-related pain or tiredness in the foot, ankle, or leg, your doctor may recommend stretching exercises for the heel cord.

Heel cord stretch

Heel cord stretch.

  • Heel Cord Stretch
    Lean forward against a wall with one leg in front of the other. Straighten your back leg and press your heel into the floor. Your front knee is bent. Hold for 15 to 30 seconds. Keep both heels flat on the floor. Point the toes of your back foot toward the heel of your front foot.  This stretch should be performed three times on each leg.

Shoe inserts (orthotics). If discomfort continues, your doctor may recommend shoe inserts. Soft-, firm-, and hard-molded arch supports may help relieve your child’s foot pain and fatigue. They can also extend the life of your child’s shoes, which may otherwise wear unevenly.

In most cases, there is little benefit to using custom-molded arch supports.  Over-the-counter arch supports, which are available at most sporting goods and running shoe stores, can be just as effective and are much less expensive to replace as your child grows. Online retailers often have inserts in difficult-to-find sizes.

Additional treatment. Your doctor may prescribe physical therapy or casting if your child has flexible flatfoot with tight heel cords.

Flexible flatfoot corrected over time

A child at age 3 years (left) with flexible flatfoot. The same child at age 15 years (right) has a normal arch despite having received no treatment. Reproduced from Sullivan JA: Pedatric Flatfoot: Evaluation and Management. J Am Acad Orthop Surg 1999;7:44-53.

Surgical Treatment

Occasionally, surgical treatment may be recommended for an adolescent with persistent pain. Surgery is typically performed to create an arch in the foot and lengthen tendons that may be tight and causing pain. The surgery is usually performed in stages. One foot is corrected then, after several months of recovery, the second surgery takes place.

In a small number of children, flexible flatfeet become rigid instead of correcting with growth. These cases may need further medical evaluation.

Questions and Answers About Metal-on-Metal Hip Implants

Questions and Answers About Metal-on-Metal Hip Implants

Article Featured on AAOS

If your hip has been damaged by arthritis, a fracture, or other condition, common activities such as walking or getting in and out of a chair may be painful and difficult. You may be considering hip replacement surgery. By replacing your diseased hip joint with an artificial joint, hip replacement surgery can relieve your pain, increase motion, and help you get back to enjoying many normal, everyday activities.

How Your Hip Works

The hip is one of the body’s largest weight-bearing joints. It is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone). Bands of tissue called ligaments (hip capsule) connect the ball to the socket and provide stability to the joint.

normal hip anatomy

Normal anatomy of the hip. In a healthy hip, the ball at the upper end of the thighbone (femur) fits firmly into the socket, which is part of the large pelvis bone.

Hip Replacement Devices

After you and your orthopaedic surgeon have determined you are a candidate for hip replacement surgery, your surgeon will select a hip replacement device for you based on your body structure, medical history, and lifestyle.

Many different types of designs and materials are currently used in artificial hip joints. All of them consist of two basic components: the ball component (made of a highly polished strong metal or ceramic material) and the socket component (a durable cup of plastic/polyethylene, ceramic, or metal). Sometimes, the socket is made of a different material than the ball, or is lined with a different material, and sometimes the ball and socket are made of the same material. Your orthopaedic surgeon will recommend the best combination for you.

Implant Complications

All hip implant devices — no matter what type — can have complications. The most common complications include implant dislocation and device wear.

Bone loss, or osteolysis, is also a known complication. When the ball component moves against the cup, the surface begins to wear away and small debris particles are given off. The debris remains around the joint and over time can cause the bone around the implant to thin and weaken. As a result, the implant components can loosen and additional surgery may be necessary.

Researchers are continuing to study different device surfaces in order to address the problems of wear debris and osteolysis.

Metal-on-Metal (MoM) Devices

In metal-on-metal devices both the ball and socket components are made of metal. These metal implants have been used in total hip replacement surgeries and hip resurfacing procedures.

Because of metal’s durability, metal-on-metal devices were expected to last longer than other hip implants. In addition, the ball in a metal-on-metal device is larger, making the hip joint more stable and less likely to dislocate.

MoM implants have also been used because they avoid the complication of debris wear from implants made of plastic/polyethylene. However, recent information about the wear of certain metal-on-metal devices has raised concerns about their use. Like polyethylene, metal surfaces give off small particles of debris. In addition, metal surfaces can corrode, giving off metal ions. Metal debris (ions and particles) can enter the space around the implant, as well as enter the bloodstream. This can cause a reaction in some patients, such as pain or swelling around the hip, osteolysis, and very rarely symptoms in other parts of the body.

Although the vast majority of patients have not had any problems with MoM implants, orthopaedic surgeons and the U.S. Food and Drug Administration (FDA) are concerned because cases have been reported in the peer-reviewed literature and through a British database in which patients have local hip symptoms (pain and swelling). In addition, there have been a very small number of cases that have had other medical concerns seemingly unrelated to the hip.

Updates on Metal-on-Metal Devices from the FDA

On January 17, 2013, the U.S. Food and Drug Administration (FDA) issued an updated public health communication about hip replacement components that have both a metal ball and a metal socket (metal-on-metal hip devices).To read their notification:

On May 6, 2011, the Food and Drug Administration (FDA) issued a postmarket surveillance study of total metal-on-metal hip replacement devices. Metal-on-metal (MoM) hip devices consist of a ball, stem, and shell, all made of metal parts. A postmarket surveillance study monitors adverse events after a device has been approved or cleared by the FDA. Manufacturers of metal-on-metal hip implants have orders from the FDA to further study the safety of metal-on-metal devices . As a result, if you have a metal-on-metal hip replacement device, your surgeon may be contacting you to find out how your device is functioning.

In February 2011, the FDA issued their initial public safety communication about metal-on-metal hip devices.

If after a joint replacement surgery you experience pain or have other, new medical concerns or issues, please talk to your doctor or orthopaedic surgeon.

The Importance of Physician-Patient Communication

The American Academy of Orthopaedic Surgeons (AAOS) believes that physician and patient joint decision making leads to the best surgical outcomes. Share your concerns, voice your questions, and offer a complete medical history so that you and your surgeon can together develop the best plan for you.

There are many issues to discuss with your orthopaedic surgeon when you are considering total hip replacement surgery. It is helpful to make a list of the questions you would like to ask. In addition to the questions featured in this article, the AAOS provides the following suggestions: Total Joint Replacement: Questions Patients Should Ask Their Surgeon

Your surgeon will also talk with you about hip implant devices. To help you with this discussion, here are examples of questions you may want to ask your surgeon:

  • What are your experiences with specific hip implant devices and how often do you use one over the other?
  • What are the risks and benefits of different devices (metal-on-metal, metal-on-polyethylene, ceramic-on-polyethylene, and ceramic-on-ceramic devices)?
  • If applicable, what is the surgeon’s personal experience and outcomes with metal-on-metal hip devices?
  • If your surgeon recommends a metal-on-metal device, ask why a metal-on-metal hip implant is the best for your situation.

Frequently Asked Questions About Metal-on-Metal Hip Implants

What kind of recovery should I expect after hip replacement surgery?

After undergoing hip replacement, you may expect your lifestyle to be a lot like the way it was before, but without the pain. In many ways, you are right, but it will take time. You need to be a partner in the healing process to ensure a successful outcome.

What personal health information should I share with my orthopaedic surgeon if I am considering a metal-on-metal hip implant?

It is critical that your orthopaedic surgeon know your complete medical history including any problems you may have with your kidneys and any known sensitivities or allergies to metal — for example, if you have allergic reactions from wearing certain jewelry.

Is there a way to determine ahead of time if I might have a reaction to the metal in the metal-on-metal hip implant system?

Currently there is no widely accepted test to predict if you will develop a reaction to the metal from a hip system, and there is insufficient evidence to support using a skin patch test to determine your sensitivity to a metal-on-metal hip implant. If, however, you have a known sensitivity to metal, it is important to share that information with your surgeon.

Are there any ways to prevent the metal from reaching the joint and bloodstream if I get a metal-on-metal hip implant?

No. All artificial hips require one component to slide against another component and it is inevitable that material at the surfaces will wear as they interact. In metal-on-metal hip implants, some tiny metal particles and metal ions are released into the joint space and metal ions can potentially enter the bloodstream. Certain characteristics may place patients at risk for increased wear and metal ion production, and these patients will need closer follow-up after implantation. However, how a patient reacts to the metal is variable.

Which patients should not have a metal-on-metal hip implant system implanted?

Each type of hip implant system has its own set of benefits and risks. Metal-on-metal hip implant systems are not for everyone. You should discuss your situation with your orthopaedic surgeon to determine whether you are a candidate or not. In general, metal-on-metal hip systems are not meant to be implanted in patients:

  • Who have kidney problems
  • Who have a known allergy or sensitivity to metals
  • Who have a suppressed immune system
  • Who are currently receiving high doses of corticosteroids such as prednisone
  • Who are women of childbearing age

In addition, people with smaller body frames may be at increased risk for adverse events and device failure.

Why are women of child-bearing age not good candidates for metal-on-metal hip implants?

As discussed above, recent information shows that metal ions can leave the artificial joint and enter the bloodstream. It is not known how long they remain in blood or other organs of the body.

Some metallic ions may cross the barrier from mother to fetus through the placenta. It is not known if the amount of ions is great enough to have any effect on the growing fetus or if the presence of metal ions in the mother’s bloodstream will have any effect on future pregnancies.

For this reason, it is recommended that younger women who need hip replacement surgery consider implant options other than metal-on-metal.

With the risk of adverse reactions to metal-on-metal hip implant systems, why are these devices still being offered to patients?

It is known that every different type of hip implant system has its own set of risks as well as its own set of benefits. FDA’s assessment of medical devices such as metal-on-metal (MoM) hip implants is based on a risk-benefit ratio with the data available. MoM hip implants overall have been shown to provide significant benefits (e.g., high survivorship) in certain patient populations. Although the exact prevalence of adverse reactions to metal debris is not known, current experience leads us to consider the adverse outcomes to be relatively low or equal (with some designs) to other types of hip implants. Thus, for many patients, currently available information supports a favorable risk-benefit ratio.

The orthopaedic surgeon should assess the patient’s individual needs and should avoid using metal-on-metal hip implants in patients where the risks outweigh the benefits.

Information for Patients Who Have Metal-on-Metal Hip Implants

How do I know if I have a metal-on-metal hip system?

Patients are usually told about the type of implant they are receiving prior to the surgery. If you are uncertain about which type you have, you should contact the orthopaedic surgeon who performed your procedure.

How often should I follow-up with my orthopaedic surgeon?

Based on your individual circumstances, your orthopaedic surgeon will determine how frequently you need to follow-up. There are some cases where your orthopaedic surgeon may recommend more frequent follow-up based on the type of hip implant, the outcome of the surgery and your recovery, and the results of blood tests or imaging procedures.

If you develop new or significantly worsening symptoms or problems with your hip, including pain, swelling, numbness and/or a change in ability to walk, contact your orthopaedic surgeon right away.

What should I discuss with my orthopaedic surgeon at each follow-up appointment?

It is critical that you talk to your surgeon about any new or worsening symptoms related to your hip, groin, or legs since your last visit. This may include pain, swelling, numbness, and change in ability to walk. It is also important that you discuss:

  • Changes in your general health
  • Whether you are being seen or treated by another physician for a new condition since receiving your metal-on-metal hip implant

What symptoms might a metal-on-metal hip implant cause?

Symptoms may include hip/groin pain, local swelling, numbness or changes in your ability to walk. There are many reasons a patient with a metal-on-metal hip implant may experience such symptoms and it is important that you contact your surgeon to help determine why you are having them.

Are there other medical effects that can occur with my metal-on-metal hip implant system?

Metal-on-metal hip implants, like other types of hip implants, are known to have adverse events, including infection and joint dislocation. There are some case reports of the metal particles causing a reaction around the joint, leading to deterioration of the tissue around the joint, loosening of the implant, and failure of the device, as well as some of the symptoms described above. In addition, some metal ions from the implant may enter into the bloodstream. There have been a few recent case reports of patients with metal-on-metal hip implants developing a reaction to these ions and experiencing medical problems that might have been related to their implants, including effects on the nervous system, heart, and thyroid gland.

What are my chances of developing a reaction to my metal-on-metal hip implant and having these types of medical problems?

Although current data suggests that these events are rare, it is currently unknown how often they occur in patients with metal-on-metal hip implants.

Part of the difficulty in answering this question is that individuals vary in how they react to metal ions in their bodies. For example, a reaction may develop in Patient A in response to a very small amount of metal, whereas Patient B may be able to tolerate a much larger amount before a reaction develops.

What should I do if I am experiencing adverse events associated with my metal-on-metal hip implant?

  1. If you are experiencing hip/groin pain, difficulty walking or a worsening of your previous symptoms, you should make an appointment to see your orthopaedic surgeon for further evaluation of your implant. Your orthopaedic surgeon may wish to perform a physical exam and an evaluation based on your symptoms.
  2. If you experience any new symptoms or medical conditions in your body other than at your hip, you should report these to your primary physician and remind them that you have a metal-on-metal hip implant system during their evaluation.

What should I do if I am not experiencing adverse events associated with my metal-on-metal hip implant?

If you are not having any symptoms and your orthopaedic surgeon believes the metal-on-metal hip implant is functioning appropriately, there are no data to support the need for additional tests. You should continue to follow-up with your orthopaedic surgeon for periodic examinations.

What should I discuss with my other healthcare providers including my general internist or family practice doctor?

There are rare case reports of patients with metal-on-metal hip implants who experienced medical problems in areas of the body away from their hip implant. This may have resulted from the metal ions released by the metal-on-metal hip implant.

If you see a healthcare provider for the evaluation of any new or worsening symptoms outside the hip/groin area, including symptoms related to your heart, nervous system, or thyroid gland, it is important that you tell that clinician of your metal-on-metal hip implant. This information may affect the types of tests that are ordered to further evaluate the cause of your symptoms.

When would a hip revision surgery be needed?

There are multiple reasons why a surgeon may recommend a device revision (a surgical procedure where your implant is removed and another put in its place). Many of these reasons, including infection, dislocation, and device fracture, apply to any type of hip implant. Your surgeon might also consider revision if you develop evidence of local or systemic reactions to the metal from your hip implant. In that case, the surgeon will take several factors into account in considering if and when a revision surgery is advisable.

What are the risks of revision surgery?

Any surgical procedure, including revision surgery, has risks associated with it, including reaction to the anesthesia, infection, bleeding, and blood clots. The revision surgery may be more difficult if you had a local reaction to the implant that may have affected your soft tissue and/or bone quality.

What does it mean when I see that a hip implant system has been “recalled?”

A hip system may be recalled by the manufacturer for a number of reasons. If your device is recalled, this does not necessarily mean that the device needs to be removed and replaced. In some cases, the recall just calls for different or more frequent monitoring. It is important to discuss the reason for the recall with your surgeon to determine the most appropriate course of action. If you are unsure if your hip implant was recalled, consult with your orthopaedic surgeon. Additional information on the recall can be obtained from the manufacturer.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Rotator Cuff and Shoulder Rehabilitation Exercises

Rotator Cuff and Shoulder Rehabilitation Exercises [PDF Handout]

To ensure that this program is safe and effective for you, it should be performed under your doctor’s supervision. Talk to your doctor or physical therapist about which exercises will best help you meet your rehabilitation goals.

After an injury or surgery, an exercise conditioning program will help you return to daily activities and enjoy a more active, healthy lifestyle. Following a well-structured conditioning program will also help you return to sports and other recreational activities.

Click to view and download this handout.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Artificial Disk Replacement in the Lumbar Spine

Artificial Disk Replacement in the Lumbar Spine

Article Featured on AAOS
In artificial disk replacement, worn or damaged disk material between the small bones in the spine (vertebrae) is removed and replaced with a synthetic or “artificial” disk. The goal of the procedure is to relieve back pain while maintaining more normal motion than is allowed with some other procedures, such as spinal fusion.

Artificial disk replacements

 

Total artificial disk replacements are mechanical devices that simulate spinal function. CHARITÉ artificial disk. Reproduced with permission from DePuy Spine, Inc. © 2007 DePuy Spine, Inc. All rights reserved.

Lumbar Fusion and Artificial Disk Replacement

Although it is estimated that 70% to 80% of people will experience low back pain at some point in their lives, most will not need surgery to improve their pain. Surgery is considered when low back pain does not improve with conservative treatment.

For patients who have exhausted nonsurgical options and are still in pain, lumbar fusion surgery remains the most common option for treating low back pain. Fusion is essentially a “welding” process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.

While many patients are helped by lumbar fusion, the results of the surgery can vary. In addition, some patients whose fusion surgeries heal perfectly still end up with no improvement of their back pain.

Some doctors believe that the failure to improve after fusion surgery is due to the fact that fusion prevents normal motion in the spine. For this reason, artificial disk replacement—which aims to preserve normal motion—has emerged as an alternative treatment option for low back pain.

Artificial disk replacement initially gained FDA approval for use in the U.S. in 2004. Over the past several years, numerous disk replacement designs have been developed and are currently being tested.

X-rays of lumbar spinal fusion and disk replacement

These x-rays, taken from the side, show patients treated with (left) lumbar spinal fusion, and (right) artificial disk replacement. (Right) From Mathur S, Jenis LG, An HS: Surgical Management of Chronic Low Back Pain: Arthrodesis, in Jenis LG, ed: Low Back Pain: Monograph Series. (Left) From Jenis LG: Surgical Management of Chronic Low Back Pain: Alternatives to Arthrodesis, in Jenis LG, ed: Low Back Pain: Monograph Series. Rosemont, IL, Amer Acad of Orthop Surg, 2005.

Who Is a Candidate for Disk Replacement?

To determine if you are a good candidate for disk replacement, your surgeon may require a few tests, including:

  • Magnetic resonance imaging (MRI) scans
  • Discography
  • Computed tomography (CT) scans
  • X-rays

Information from these tests will also help your surgeon determine the source of your back pain.

Artificial disk replacement is not appropriate for all patients with low back pain. In general, good candidates for disk replacement have the following characteristics:

  • Back pain caused by one or two problematic intervertebral disks in the lumbar spine
  • No significant facet joint disease or bony compression on spinal nerves
  • Body size that is not excessively overweight
  • No prior major surgery on the lumbar spine
  • No deformity of the spine (scoliosis)

Surgical Procedure

Most artificial disk replacement surgeries take from 2 to 3 hours.

Your surgeon will approach your lower back from the front through an incision in your abdomen. With this approach, the organs and blood vessels must be moved to the side. This allows your surgeon to access your spine without moving the nerves. Usually, a vascular surgeon assists the orthopaedic surgeon with opening and exposing the disk space.

During the procedure, your surgeon will remove your problematic disk and then insert an artificial disk implant into the disk space.

Disk Design

Some disk replacement devices comprise the nucleus (center) of the intervertebral disk while leaving the annulus (outer ring) in place, although this technology is still in an investigative stage.

In most cases, total artificial disk replacements substitute both the annulus and nucleus with a mechanical device that will simulate spinal function.

There are a number of different disk designs. Each is unique in its own way, but all maintain a similar goal: to reproduce the size and function of a normal intervertebral disk.

Some disks are made of metal, while others are a combination of metal and plastic, similar to joint replacements in the knee and hip. Materials used include medical grade plastic (polyethylene) and medical grade cobalt chromium or titanium alloy.

Your surgeon will talk with you about which disk design is best for you.

Examples of artificial disk replacements

Examples of total artificial disk replacements. A. CHARITÉ artificial disk. Reproduced with permission from DePuy Spine, Inc. © 2007 DePuy Spine, Inc. All rights reserved. B. ProDisc-L prostheses. Reproduced with permission from Synthes, West Chester, PA.

Recovery

In most cases, you will stay in the hospital for 1 to 3 days following artificial disk replacement. The length of your stay will depend upon how well-controlled your pain is and your return to function.

In most cases, patients are encouraged to stand and walk by the first day after surgery. Because bone healing is not required following artificial disk replacement, the typical patient is encouraged to move through the mid-section. Early motion in the trunk area may lead to quicker rehabilitation and recovery.

You will perform basic exercises, including routine walking and stretching, during the first several weeks after surgery. During this time, it is important to avoid any activities that cause you to hyperextend your back.

Outcomes

Most patients can expect improvement of lower back pain and disability in weeks to months following surgery. Studies show that disk replacement improves, but does not completely eliminate pain. Before your surgery, it is important to talk with your surgeon about realistic expectations for pain relief.

Research On the Horizon

The future of artificial disk replacement technology will likely include advancements in the design of implants and tools for diagnosing the source of pain, as well as the development of ways to return the disk to normal function without the insertion of any biomechanical device.

Although no longer considered a new technology, the development of artificial disk replacement is more recent than that of lumbar fusion. Follow-up studies to 10 years have shown satisfactory outcomes in a carefully chosen patient population. Despite the theoretical advantages of preserving motion, some studies have not shown a clear advantage of artificial disk replacement over lumbar fusion. Research continues on the outcomes of the procedure.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Do you need bunion surgery

Do you need bunion surgery?

Article Featured on AAOS

Most people with bunions find pain relief with simple treatments to reduce pressure on the big toe, such as wearing wider shoes or using pads in their shoes. However, if these measures do not relieve your symptoms, your doctor may recommend bunion surgery.

There are different types of surgeries to correct a bunion. Bringing the big toe back to its correct position may involve realigning bone, ligaments, tendons, and nerves.

Are You a Candidate for Surgery?

In general, if your bunion is not painful, you do not need surgery. Although bunions often get bigger over time, doctors do not recommend surgery to prevent bunions from worsening. Many people can slow the progression of a bunion with proper shoes and other preventive care, and the bunion never causes pain or other problems.

It is also important to note that bunion surgery should not be done for cosmetic reasons. After surgery, it is possible for ongoing pain to develop in the affected toe — even though there was no bunion pain prior to surgery.

Good candidates for bunion surgery commonly have:

  • Significant foot pain that limits their everyday activities, including walking and wearing reasonable shoes. They may find it hard to walk more than a few blocks (even in athletic shoes) without significant pain.
  • Chronic big toe inflammation and swelling that does not improve with rest or medications
  • Toe deformity—a drifting in of the big toe toward the smaller toes, creating the potential for the toes to cross over each other.

Photo and x-ray of foot deformed by a bunion

(Left) A bunion that has progressed to deformity with the big toe crossing over the second toe. (Right) An x-ray of the same bunion shows how far out of alignment the bones are.

Reproduced from Wagner E, Ortiz C: Proximal Oblique Sliding Closing-wedge Osteotomy for Wide-angle Hallux Valgus. Orthopaedic Knowledge Online Journal: Vol 12, No 4, 4/1/2014; Accessed December 4, 2015.

  • Toe stiffness—the inability to bend and straighten the big toe
  • Failure to obtain pain relief with changes in footwear
  • Failure to obtain pain relief from nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen. The effectiveness of NSAIDs in controlling toe pain varies greatly from person to person.

Deciding to Have Bunion Surgery

After bunion surgery, most patients have less foot pain and are better able to participate in everyday activities.

As you explore bunion surgery be aware that so-called “simple” or “minimal” surgical procedures are often inadequate “quick fixes” that can do more harm than good. Although many bunion procedures are done on a same-day basis with no hospital stay, a long recovery period is common. It often takes up to 6 months for full recovery, with follow-up visits to your doctor sometimes necessary for up to a year.

It is very important to have realistic expectations about bunion surgery. For example, bunion surgery may not allow you to wear a smaller shoe size or narrow, pointed shoes. In fact, you may need to restrict the types of shoes you wear for the rest of your life.

As you consider bunion surgery, do not hesitate to ask your doctor questions about the operation and your recovery. Some examples of helpful questions to ask include:

  • What are the benefits and risks of this surgery?
  • What are the possible complications and how likely are they to occur?
  • How much pain will there be and how will it be managed?

Be sure to write down your doctor’s answers so you can remember them at a later time. It is important to understand both the potential benefits and limitations of bunion surgery.

Surgical Procedures

In general, the common goals of most bunion surgeries include:

  • Realigning the metatarsophalangeal (MTP) joint at the base of the big toe
  • Relieving pain
  • Correcting the deformity of the bones making up the toe and foot

Because bunions vary in shape and size, there are different surgical procedures performed to correct them. In most cases, bunion surgery includes correcting the alignment of the bone and repairing the soft tissues around the big toe.

Your doctor will talk with you about the type of surgery that will best correct your bunion.

Repairing the Tendons and Ligaments Around the Big Toe

In some cases, the soft tissues around the big toe may be too tight on one side and too loose on the other. This creates an imbalance that causes the big toe to drift toward the other toes.

Surgery can shorten the loose tissues and lengthen the tight ones. This is rarely done without some type of alignment of the bone, called an osteotomy. In the majority of cases, soft tissue correction is just one portion of the entire bunion corrective procedure.

Osteotomy

In an osteotomy, your doctor makes small cuts in the bones to realign the joint. After cutting the bone, your doctor fixes this new break with pins, screws, or plates. The bones are now straighter, and the joint is balanced.

Osteotomies may be performed in different places along the bone to correct the deformity. In some cases, in addition to cutting the bone, a small wedge of bone is removed to provide enough correction to straighten the toe.

As discussed above, osteotomies are normally performed in combination with soft tissue procedures, as both are often necessary to maintain the big toe alignment.

Foot x-rays showing a bunion corrected with osteotomy

X-rays taken from the top and the side of the foot show a bunion corrected with osteotomy.

Arthrodesis

In this procedure, your doctor removes the arthritic joint surfaces, then inserts screws, wires, or plates to hold the surfaces together until the bones heal. Arthrodesis is commonly used for patients who have severe bunions or severe arthritis, and for patients who have had previous unsuccessful bunion surgery.

X-rays of an arthritic foot before and after arthrodesis

The x-ray on the left shows severe arthritis of the MTP joint. After arthrodesis (shown on the right), the entire foot is realigned. An advantage of arthrodesis is that no additional procedures are necessary to correct the bunion.

Exostectomy

In this procedure, your doctor removes the bump from your toe joint. Exostectomy alone is seldom used to treat bunions because it does not realign the joint. Even when combined with soft tissue procedures, exostectomy rarely corrects the cause of the bunion.

Exostectomy is most often performed as one part of an entire corrective surgery that includes osteotomy, as well as soft-tissue procedures. If a doctor performs exostectomy without osteotomy, however, the bunion deformity often returns.

X-rays of a bunion before and after exostectomy

The x-ray on the left shows a mild bunion bump before exostectomy. After the procedure (right), the bump has been shaved but the toe deformity remains and is actually worse; the big toe drifts closer to the other toes and the metatarsal bone sticks out further.

Resection Arthroplasty

In this procedure, your doctor removes the damaged portion of the joint. This increases the space between the bones and creates a flexible “scar” joint. Resection arthroplasty is used mainly for patients who are elderly, have had previous unsuccessful bunion surgery, or have severe arthritis not amenable to an arthrodesis (see above). Because this procedure can change the push off power of the big toe, it is not often recommended.

X-ray of a failed resection arthroplasty and photo of a shortened big toe

This x-ray shows a failed resection arthroplasty. Although the damaged bone of the MTP joint was removed, scar tissue did not fill the space between the bones. The bone edges are still in contact. The photograph shows that without the needed scar tissue, the big toe is shortened. This makes it more difficult to push off while walking.

Preparing for Surgery

Medical Evaluation

Before your surgery, you may be asked to visit your family doctor for a complete physical examination. He or she will assess your health and identify any problems that could interfere with your surgery. If you have a heart or lung condition or a chronic illness you will need a preoperative medical clearance from your family doctor.

Medications

Tell your doctor about any medications you are taking. He or she will tell you which medications you can continue taking and which you should stop taking before surgery.

Tests

You may require several preoperative tests, including blood counts, a cardiogram, and a chest x-ray. You may also need to provide a urine sample.

To help plan your procedure, your doctor may order special foot x-rays. These x-rays should be taken in a standing, weight bearing position to ensure your doctor can clearly see the deformity in the foot. These x-rays assist your doctor in making decisions about where along the bone to perform an osteotomy in order to provide enough corrective power to straighten the toe.

Your Surgery

In planning your surgery, your doctor will consider several things, including how severe your bunion is, your age, your general health and activity level, and any other medical issues that may affect your recovery.

Almost all bunion surgery is done on an outpatient basis. You will most likely be asked to arrive at the hospital or surgical center 1 or 2 hours before your surgery.

Anesthesia

After admission, you will be evaluated by a member of the anesthesia team. Most bunion surgery is performed with anesthesia that numbs the area for surgery but does not put you to sleep.

  • Local anesthesia. An ankle block numbs just your foot.
  • Regional anesthesia. A popliteal block works for a longer period of time compared to an ankle block and numbs more of the leg. The numbing medicine is injected behind the knee.
  • Spinal anesthesia. This injection will numb your body below your waist.
  • General anesthesia. This form of anesthesia will put you to sleep.

The anesthesiologist will stay with you throughout the procedure to administer other medications, if necessary, and to make sure you are comfortable.

Procedure

Depending upon your bunion and the procedures you need, your doctor will make an incision along the inside of your big toe joint or on top of the joint. In some cases, more than one incision is needed to correct the bunion deformity.

Surgical photo of an osteotomy

This surgical photograph shows a saw cutting the bone to perform an osteotomy.

The surgical time varies depending on how much of your foot is malaligned. Surgery will take longer if your deformity is greater or if more than one osteotomy is required. Every bunion correction is a little bit different, and there is no reason to be concerned if your surgery takes more time.

Afterward, you will be moved to the recovery room. You will be ready to go home in an hour or two. Be sure to have someone with you to drive you home.

Photo and x-ray of a foot after osteotomy for a bunion

(Left) The bunion that was shown at the beginning of this article as it appeared immediately after surgery. (Right) An x-ray showing the bones in alignment after surgery. Osteotomies were performed on both bones; screws and plates hold the bones in place. Reproduced from Wagner E, Ortiz C: Proximal Oblique Sliding Closing-wedge Osteotomy for Wide-angle Hallux Valgus. Orthopaedic Knowledge Online Journal: Vol 12, No 4, 4/1/2014; Accessed December 4, 2015.

Complications

As with any surgical procedure, there are risks associated with bunion surgery. These occur infrequently and are usually treatable — although, in some cases, they may limit or extend your full recovery. Before your surgery, your doctor will discuss each of the risks with you and take specific measures to avoid complications.

The possible risks and complications of bunion surgery include:

  • Infection
  • Nerve injury
  • Failure to relieve pain
  • Failure of the bone to fully heal
  • Stiffness of the big toe joint
  • Recurrence of the bunion

Recovery at Home

The success of your surgery will depend in large part on how well you follow your doctor’s instructions at home during the first few weeks after surgery. You will see your doctor regularly for several months — occasionally up to a year — to make sure your foot heals properly.

Dressing Care

You will be discharged from the hospital with bandages holding your toe in its corrected position.

Because keeping your toe in position is essential for successful healing, it is very important to follow your doctor’s directions about dressing care. Do not disturb or change the dressing without talking to your doctor. Interfering with proper healing could cause a recurrence of the bunion.

Dressing applied to foot after osteotomy

Legend: Your doctor will apply your dressing in a specific way to keep the bones in correct position.

Reproduced from Hirose CB, Coughlin MJ: Proximal and Distal First Metatarsal Osteotomies for Hallux Valgus, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 535-539.

Be sure to keep your wound and dressing dry. When you are showering or bathing, cover your foot with a plastic bag.

Your sutures will be removed about 2 weeks after surgery, but your foot will require continued support from dressings or a brace for 6 to 12 weeks.

Medications

Your doctor will prescribe pain medication to relieve surgical discomfort. The most effective medications for providing postsurgical pain relief are opioids. These medications are narcotics, however, and can be addictive. It is important to use opioids only as directed by your doctor.

As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

In addition to pain medicine, your doctor may prescribe antibiotics to help prevent infection in your wound for several days after surgery.

Swelling

Keep your foot elevated as much as possible for the first few days after surgery, and apply ice as recommended by your doctor to relieve swelling and pain. Never apply ice directly on your skin. It is common to have some swelling in your foot from 6 months to a year after bunion surgery.

Bearing Weight

Your doctor will give you strict instructions about whether and when you can put weight on your foot. Depending upon the type of procedure you have, if you put weight on your foot too early or without proper support, the bones can shift and the bunion correction will be lost.

Some bunion procedures allow you to walk on your foot right after the surgery. In these cases, patients must use a special surgical shoe to protect the bunion correction.

Many bunion surgeries require a period of no weightbearing to ensure bone healing. Your doctor will apply dressings, a brace, or a cast to maintain the correct bone position. Crutches are usually used to avoid putting any weight on the foot. A newer device called a knee walker is a good alternative to crutches. It has four wheels and functions like a scooter. Instead of standing, you place the knee of your affected foot on a padded cushion and push yourself along using your healthy foot.

In addition to no weightbearing, driving may be restricted until the bones have healed properly — particularly if the surgery was performed on your right foot.

No matter what type of bunion surgery you have, it is very important to follow your doctor’s instructions about weightbearing. Do not put weight on your foot or stop using supportive devices until your doctor gives approval.

Physical Therapy and Exercise

Specific exercises will help restore your foot’s strength and range of motion after surgery. Your doctor or physical therapist may recommend exercises using a surgical band to strengthen your ankle or using marbles to restore motion in your toes.

Marble pick-up exercise for foot

Specific exercises such as the marble pick up exercise will help restore full motion to your foot.

Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Always start these exercises slowly and follow instructions from your doctor or physical therapist regarding repetitions.

Shoe Wear

It will take several months for your bones to fully heal. When you have completed the initial rehabilitation period, your doctor will advise you on shoewear. Athletic shoes or soft leather oxford type shoes will best protect the bunion correction until the bones have completely healed.

To help prevent your bunion from recurring, do not wear fashion shoes until your doctor allows it. Be aware that your doctor may recommend that you never return to wearing high-heeled shoes.

Avoiding Complications

Though uncommon, complications can occur following bunion surgery. During your recovery at home, contact your doctor if:

  • Your dressing loosens, comes off, or gets wet.
  • Your dressing is moistened with blood or drainage.
  • You develop side effects from postoperative medications.

Also, call your doctor immediately if you notice any of the following warning signs of infection:

  • Persistent fever
  • Shaking chills
  • Persistent warmth or redness around the dressing
  • Increased or persistent pain, especially a “sunburn” type pain
  • Significant swelling in the calf above the treated foot, especially if there is a “charley horse” pain behind the knee, or if your develop shortness of breath.

Outcomes

The majority of patients who undergo bunion surgery experience a reduction of foot pain, along with improvement in the alignment of their big toe. The length of your recovery will depend upon the surgical procedures that were performed, and how well you follow your doctor’s instructions.

Because a main cause of bunion deformity is a tight-fitting shoe, returning to that type of shoe can cause your bunion to return. Always follow your doctor’s recommendations for proper shoe fit.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Cervical Spondylotic Myelopathy (Spinal Cord Compression)

Cervical Spondylotic Myelopathy (Spinal Cord Compression)

Article Featured on AAOS

Cervical spondylotic myelopathy (CSM) is a neck condition that arises when the spinal cord becomes compressed—or squeezed—due to the wear-and-tear changes that occur in the spine as we age. The condition commonly occurs in patients over the age of 50.

Because the spinal cord carries nerve impulses to many regions in the body, patients with CSM can experience a wide variety of symptoms. Weakness and numbness in the hands and arms, loss of balance and coordination, and neck pain can all result when the normal flow of nerve impulses through the spinal cord is interrupted.

Anatomy

Your spine is made up of 24 bones, called vertebrae, that are stacked on top of one another. The seven small vertebrae that begin at the base of the skull and form the neck comprise the cervical spine.

The areas of the spine

Cervical spondylotic myelopathy occurs in the cervical spine—the seven small vertebrae that form the neck

Other parts of your spine include:

Spinal cord and nerves. The spinal cord extends from the skull to your lower back and travels through the middle part of each stacked vertebra, called the central canal. Nerves branch out from the spinal cord through openings in the vertebrae (foramen) and carry messages between the brain and muscles.

Spinal nerve root

Spinal nerve root.

Intervertebral disks. In between your vertebrae are flexible intervertebral disks. They act as shock absorbers when you walk or run.

Intervertebral disks are flat and round and about a half inch thick. They are made up of two components:

  • Annulus fibrosus. This is the tough, flexible outer ring of the disk.
  • Nucleus pulposus. This is the soft, jelly-like center of the disk.

Cause

Cervical spondylotic myelopathy (CSM) arises from degenerative changes that occur in the spine as we age. These degenerative changes in the disks are often called arthritis or spondylosis.

Cervical Disk Degeneration

Bone spurs. As the disks in the spine age, they lose height and begin to bulge. They also lose water content, begin to dry out, and become stiffer. This problem causes settling, or collapse, of the disk spaces and loss of disk space height.

As the disks lose height, the vertebrae move closer together. The body responds to the collapsed disk by forming more bone—called bone spurs—around the disk to strengthen it. These bone spurs contribute to the stiffening of the spine. They may also make the spinal canal narrow—compressing or squeezing the spinal cord.

Illustrations of a healthy cervical vertebra and disk and a disk that has collapsed

(Left) Side view of a healthy cervical vertebra and disk. (Right) A disk that has degenerated and collapsed.

Herniated disk. A disk herniates when its jelly-like center (nucleus pulposus) pushes against its outer ring (annulus fibrosus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When a herniated disk bulges out toward the spinal canal, it can put pressure on the spinal cord or nerve roots.

As disks deteriorate with age, they become more prone to herniation. A herniated disk often occurs with lifting, pulling, bending, or twisting movements.

Cross-section and side views of a herniated disk

Herniated disk (cross-section and side views)

Other Causes of Myelopathy

Myelopathy can arise from other conditions that cause spinal cord compression, as well. Although these conditions are not related to disk degeneration, they may result in the same symptoms as CSM.

Rheumatoid arthritis. Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. In rheumatoid arthritis, immune cells attack the synovium, the thin membrane that lines the joints.

As the synovium swells, it may lead to pain and stiffness and, in severe cases, destruction of the facet joints in the cervical spine. When this occurs, the upper vertebra may slide forward on top of the lower vertebra, reducing the amount of space available for the spinal cord.

Injury. An injury to the neck—such as from a car accident, sports, or a fall—may also lead to myelopathy.

For example, a “rear end” car collision may result in hyperextension, a backward motion of the neck beyond its normal limits, or hyperflexion, a forward motion of the neck beyond its normal limits. Because these types of injuries often affect the muscles and ligaments that support the vertebrae, they may lead to spinal cord compression.

Symptoms

Typically, the symptoms of CSM develop slowly and progress steadily over several years. In some patients, however, the condition may worsen more rapidly.

Patients with CSM may experience a combination of the following symptoms:

  • Tingling or numbness in the arms, fingers, or hands
  • Weakness in the muscles of the arms, shoulders, or hands. You may have trouble grasping and holding on to items.
  • Imbalance and other coordination problems. You may have trouble walking or you may fall down. With myelopathy, there is no sensation of spinning, or “vertigo.” Rather, your head and eyes feel steady, but your body feels unable to follow through with what you are trying to do.
  • Loss of fine motor skills. You may have difficulty with handwriting, buttoning your clothes, picking up coins, or feeding yourself.
  • Pain or stiffness in the neck

Doctor Examination

Physical Examination

After discussing your medical history and general health, your doctor will ask you about your symptoms. He or she will conduct a thorough examination of your neck, shoulders, arms, hands, and legs, looking for:

  • Changes in reflexes—including the presence of hyper-reflexia, a condition in which reflexes are exaggerated or overactive
  • Numbness and weakness in the arms, hands, and fingers
  • Trouble walking, loss of balance, or weakness in the legs
  • Atrophy—a condition in which muscles deteriorate and shrink in size

Tests

X-rays. These provide images of dense structures, such as bone. An x-ray will show the alignment of the vertebrae in your neck.

Magnetic resonance imaging (MRI) scans. These studies create better images of the body’s soft tissues. An MRI can show spinal cord compression and help determine whether your symptoms are caused by damage to soft tissues—such as a bulging or herniated disk.

MRI scan of a herniated disk pressing on spinal cord

This MRI image shows herniated disks pressing on the spinal cord (red arrows). Reproduced from Boyce R, Wang J: Evaluation of neck pain, radiculopathy and myelopathy: imaging, conservative treatment, and surgical indications. Instructional Course Lectures 52. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp.489-495.

Computed tomography (CT) scans. More detailed that a plain x-ray, a CT scan can show narrowing of the spinal canal and can help your doctor determine whether you have developed bone spurs in your cervical spine.

CT scan showing narrowing of the spinal canal due to bone spurs

This CT scan shows bone spurs that have led to narrowing of the spinal canal (arrows).

Myelogram. This is a special type of CT scan. In this procedure, a contrast dye is injected into the spinal column to make the spinal cord and nerve roots show up more clearly.

Treatment

Nonsurgical Treatment

In milder cases, initial treatment for CSM may be nonsurgical. The goal of nonsurgical treatment is to decrease pain and improve the patient’s ability to perform daily activities. Nonsurgical treatment options include:

Soft cervical collar. This is a padded ring that wraps around the neck and is held in place with velcro. Your doctor may advise you to wear a soft cervical collar to allow the muscles of the neck to rest and limit neck motion. A soft collar should only be worn for a short period of time since long-term wear may decrease the strength of the muscles in your neck.

Physical therapy. Specific exercises can help relieve pain, strengthen neck muscles, and increase flexibility. Physical therapy can also help you maintain strength and endurance so that you are better able to perform your daily activities. In some cases, traction can be used to gently stretch the joints and muscles of the neck.

Medications. In some cases, medications can help improve your symptoms.

  • Nonsteroidal anti-inflammatory medications (NSAIDs). Drugs like aspirin, ibuprofen, and naproxen can help relieve pain from reduce inflammation.
  • Oral corticosteroids. A short course of oral corticosteroids may help relieve pain by reducing inflammation.
  • Epidural steroid injection. Although not often used to treat CSM, in this procedure, steroids are injected into the space next to the covering of the spinal cord (the “epidural” space) to help reduce local inflammation. Although a steroid injection may temporarily help relieve pain and swelling, it will not relieve pressure on the spinal cord.
  • Narcotics. These medications are reserve for patients with severe pain that is not relieved by other options. Narcotics are usually prescribed for a limited time only.

Although people sometimes turn to chiropractic manipulation for neck and back pain, manipulation should never be used for spinal cord compression.

Surgical Treatment

If nonsurgical treatment does not relieve your symptoms, your doctor will talk with you about whether you would benefit from surgery. The majority of patients with symptoms and tests consistent with CSM are recommended to have surgery.

There are several procedures that can be performed to help relieve pressure on the spinal cord. The procedure your doctor recommends will depend on many factors, including what symptoms you are experiencing and the levels of the spinal cord that are involved.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Seven Most Common Knee Injuries

Seven Most Common Knee Injuries

Article Featured on ReboundMD

The knee joint is one of the largest and most complex joints in the body. It is also one of the most important joints. Connecting the thigh bone to the shinbone, it plays an important role in supporting the body’s weight, and facilitating movement –allowing you to bend your knee.

Due to the complexity of the knee joint, it is susceptible to a number of different injuries. Some of the most common knee joint injuries include tears in the ligaments, tendons, and cartilage. The kneecap itself can also be fractured or dislocated.

Let’s look at some of the most common knee injuries. See how they are caused and the treatment that’s required to address them.

Fractures

The kneecap (patella) is a shield for your knee joint, and protects it from becoming injured or damaged during a fall. Because of this, the kneecap can become broken during a high impact fall or sports injury.

Kneecap fractures are a common yet serious injury that usually requires immobilization or in some cases surgery to correct.

Dislocations

Knee dislocations occur when the knee bones become out of place. This can occur after a major trauma such as a fall, car crash, or high-speed impact. It can also be caused by twisting the knee while one foot is firmly planted on the ground.

Dislocations require relocation. Sometimes the kneecap will spontaneously correct itself and return to the proper position. Other cases will require a mild sedative to allow the doctor to relocate the knee without causing too much discomfort. It generally takes about six weeks to fully heal from a dislocated knee.

Anterior Cruciate Ligament Injuries

The anterior cruciate ligament (ACL) is knee tissue that joins the upper and lower leg bones together and helps keep the knee stable.

The ACL can be torn if the lower leg extends forward too much or if the leg becomes twisted. ACL injuries are one of the most common types of knee injuries and account for about 40 percent of all sports-related injuries.

An ACL injury can range from a small tear in the ligament to a severe injury –when the ligament completely tears or becomes separated from the bone itself.

Treatment options for ACL injuries depend on the extent of the injury. Not all ACL injuries require surgery, however depending on various factors including the severity of the tear, surgery may be required. Physical rehabilitation is often recommended after an ACL injury.

Posterior Cruciate Ligament Injuries

The posterior cruciate ligament connects the femur bone to the shinbone and keeps the shinbone from moving too far back. As the name suggests, this ligament is located at the back of the knee.

A posterior cruciate ligament injury occurs when trauma occurs to the knee –this can happen in sports when the player lands on a bent knee. If the damage is only to the posterior cruciate ligament –then treatment is generally non-surgical. But if there are a combination of injuries such as a dislocated knee and multiple torn ligaments, then surgery may be required.

Collateral Ligament Injuries

The collateral ligament is one of the four major ligaments in the knee.

A collateral ligament injury is a common sports-related injury. This ligament can easily be torn when the lower leg is forced sideways.

Surgery may not be required if the collateral ligament has been torn. However, if other structures in the knee are injured at the same time then surgery is generally recommended.

Meniscal Tears

The meniscus is the piece of cartilage between the knee joint that helps absorb the shock that occurs when running or playing sports. The pieces help cushion the joint and keep it stable.

Unfortunately though, meniscus tears are common in sports that require jumping –like volleyball and soccer, as well as contact sports like football. When a person changes direction suddenly while running, the meniscus can tear.

Surgery may be required, depending on the extent of the injury and severity of the tear.

Tendon Tears

The tendon in the knee, known as the patellar tendon –works together with the knee muscles in the front of the thigh to help straighten the leg. While tears in the patellar tendon are most common among middle-aged people and those who play running or jumping sports –it is possible for anyone to tear their tendon.

A complete tear is considered a disabling injury and requires surgery to regain complete function. However most tears are only partial tears and require rest and physical therapy to help facilitate healing.

If you have experienced a knee injury or are experiencing knee pain, it’s important to see an orthopedic specialist as soon as possible. Your orthopedist will be able to make a diagnosis and recommend treatment options to help get you back on track as soon as possible.

Alternative Methods to Help Manage Pain After Orthopaedic Surgery

Alternative Methods to Help Manage Pain After Orthopaedic Surgery

Article Featured on AAOS

After orthopaedic surgery, your doctors and nurses will make every effort to control your pain. While you should expect to feel some discomfort, advancements in pain control now make it easier for your doctor to manage and relieve pain.

Surgeons and their patients are increasingly using alternative methods, such as relaxation techniques and acupuncture, to supplement conventional medicine. A combined approach to pain management is often the best option because it allows the surgeon to tailor pain control methods to each individual patient.

This article focuses on alternative approaches your doctor may recommend for pain management.

Transcutaneous Electrical Nerve Stimulation (TENS)

In transcutaneous electrical nerve stimulation (TENS) a special device transmits low-level electrical charges into the area of the body that is in pain.

A TENS system consists of a small, battery-powered machine connected by wires to a pair of electrodes. The two electrodes are connected to your skin near the source of pain or at a pressure point. A mild electrical current travels through your skin and along your nerve fibers which may cause a warm, tingling sensation. A typical TENS session lasts anywhere from 5 to 15 minutes.

Many studies have found that TENS is useful in easing pain after surgery, as well as pain related to injuries, such as fractures and sprains. TENS may also be helpful for some chronic pain conditions, particularly low back pain. TENS is generally considered safe. However, its routine use is not recommended.

There is also an acupuncture version of TENS in which the electrical impulses are sent through acupuncture needles instead of electrode pads. This form of TENS is called “electro-acupuncture” or percutaneous electrical nerve stimulation (PENS).

How TENS Works

There are several ways TENS is thought to relieve pain:

Gate Control Theory. In order for you to feel pain, the sensation must travel through a “gate” to get to the brain. Normally, the pain is allowed to flow freely through the gate because it (pain) is the only sensation trying to get through. However, if the gate becomes flooded with another type of sensation (in this case, an electric current), the gate will reach capacity and no longer have room for the underlying pain sensation to get through.

Release of Endogenous Opiates. Some scientists believe that TENS works by forcing certain nerve cells to release more of the body’s natural pain killers called “endorphins.” This causes you to feel less pain.

Central Inhibitory Effect. TENS may also work by changing the way your brain perceives pain.

When to Avoid TENS

TENS might not work as well if your pain is caused by mental or emotional problems. It also does not work as well if you suffer from drug addiction.

TENS should not be used if you have any of the following conditions:

  • Implanted medical device (defibrillator or pacemaker)
  • Pregnancy
  • Epilepsy
  • Mental retardation
  • Undiagnosed pain

Continuous Passive Motion

Continuous passive motion (CPM) is a technique in which your joint is moved constantly in a mechanical splint to prevent stiffness and increase range of motion. A CPM machine moves your joint for you without requiring you to exert any effort.

Medical evidence indicates that in many cases immobilization increases pain after surgery. As a result, early motion has been applied to many orthopaedic problems. CPM is thought to be most effective in the rehabilitation treatment of:

  • Cartilage damage
  • A bacterial infection inside a joint
  • A fracture around a joint after it has been fixed with internal devices

CPM is believed to enhance the nutrition of your joint, discourage the formation of scar tissue, and prevent the abnormal shortening of the muscles surrounding your joints.

CPM machine

This CPM machine cradles the lower leg and gently moves it.

If you can already move — either actively or passively — without CPM, then using the device will not be beneficial. CPM is not a substitute for working with an experienced physical therapist who is trained to provide both active and passive motion exercises. If your doctor recommends CPM, you will also be monitored by a physical therapist.

The most important time to use a CPM device seems to be in the first 2 to 7 days after surgery, for about 4 to 6 hours every day.

Initially, CPM was only used in hospitals or outpatient physical therapy clinics, but today, CPM units can be purchased for use at home.

Acupuncture

When acupuncture is combined with traditional pain relief methods, it may be helpful for some types of chronic pain:

  • Low back pain
  • Osteoarthritis
  • Fibromyalgia
  • Aching muscle pain (knots)
  • Tennis elbow
  • Carpal tunnel syndrome
  • Stroke rehabilitation

Acupuncture points tend to be areas of your skin that contain relatively large amounts of intersecting nerve endings that feed into your muscles or bones. Some scientists believe that these “acupoints” possess special electrical characteristics that can be manipulated using painless hair-thin needles.

A typical acupuncture procedure lasts for about 30 minutes. Treatments are used to relieve local pain and swelling, as well as to provide a more general feeling of relaxation due to the release of your body’s natural painkillers, called endorphins.

Because each acupoint is responsible for producing effects in different areas of the body, it is important to be clear with your provider about the specific area and intensity of your pain. The acupuncturist can then target the correct acupoint.

Psychological Methods

Psychological methods can be effective as an additional treatment for pain control. These methods can reduce or eliminate the need for medication. Some of oldest and best documented psychological methods include:

  • Relaxation techniques
  • Guided imagery
  • Medical hypnosis

In 18 medical research studies, medical hypnosis, guided imagery, or relaxation techniques were used to improve recovery after surgery. In 16 of the studies (4 were orthopaedic surgeries), researchers documented improvements in both the physical and emotional recoveries of the patients.

These results demonstrated that psychological methods are effective as an additional treatment for pain management, postsurgical recovery (physical and emotional), and orthopaedic rehabilitation.

These methods appear to have potential in orthopaedic surgery that could reduce pain, enhance treatment outcomes, and contain or even reduce medical costs.

Bone, Joint, and Muscle Infections in Children

Bone, Joint, and Muscle Infections in Children

Article Featured on AAOS

Children can develop infections in their bones, joints, or muscles. Often referred to as “deep” infections, the technical names for these conditions are:

  • Osteomyelitis (bone infection)
  • Septic arthritis (joint infection)
  • Pyomyositis (muscle infection)

This article covers the most common types of deep infections in children and includes the ways doctors identify and treat them.

Cause

Infections are usually caused by bacteria that are present in our normal living environment. The most common bacteria causing bone, joint, or muscle infections in children is Staphylococcus aureus (often referred to as “Staph” infections).

Bacteria can get into the body in a variety of ways. They circulate through the bloodstream until they reach a bone, joint, or muscle. Bacteria then leave the bloodstream and multiply in the bone, joint, or muscle tissues.

Description

Deep infections most often occur in the joints and at the ends of long bones where they meet to form joints. These include the hip, knee, and ankle joints of the leg, and the shoulder, elbow, and wrist joints of the arm.

The large muscle groups of the thigh, groin, and pelvis are the most common locations for deep muscle infections.

The reason infections occur in these areas is due to the way blood flows to these locations. There is a strong blood flow to the ends of bone near growth centers (called growth plates), the lining of the joints, and the large muscle groups. This allows bacteria to easily find their way to these areas.

The blood supply to the spine, pelvis, and heel is similar to that of the long bones, and infections often develop in these areas, as well.

Infections pose special risks to young children for a number of reasons:

  • Children under the age of three are easily infected. Their immune systems are not fully developed and they tend to fall down a lot, opening the skin to infection.
  • Infections spread quickly through a young child’s circulation system and bone structure.
  • Damage to bones and joints caused by infection can harm a child’s growth and lead to physical dysfunction. Infection of child’s hip joint is a surgical emergency.

Symptoms and Signs

Children who have infections of their bones, joints, or muscles often have the following:

  • Fever
  • Pain
  • Limited movement of the infected area — your child may limp or refuse to walk if the infection involves the legs or back
  • Infants may be irritable and lethargic, refuse to eat, or vomit

Many children who have bone, joint, or muscle infections have had recent injuries. The symptoms of infection are often masked by those of the injury. Because parents assume the injury will get better over time, it may take them longer to notice the infection.

It is important to bring your child to a doctor immediately if symptoms are not quickly resolving at home.

Doctor Examination

Medical History and Physical Examination

Make sure to tell your child’s doctor the circumstances surrounding the symptoms, such as when the symptoms began, and whether there was a prior infection or injury.

After discussing your child’s symptoms and medical history, your doctor will examine the painful area. He or she may ask your child to move the affected area to see whether movement increases the pain.

Tests

Other tests that may help your doctor confirm a diagnosis and plan your child’s treatment include:

  • Blood tests and tissue cultures. Tests on your child’s blood, as well as fluid and/or tissue from the infected area, can help identify the bacteria or other organism causing the infection. This information about the infection helps your doctor determine the most effective ways to treat it.
  • Imaging tests. Tests, such as x-rays, magnetic resonance imaging (MRI) scans, and ultrasound, provide your child’s doctor with pictures of the bones, muscles, and soft tissues in the affected area. Your doctor will look for swelling around bones and muscles, or fluid within the joints that are infected. This information helps your doctor when making the decision whether to treat the infection with antibiotics alone or to perform surgery to help resolve it.

Treatment

Antibiotic Treatment

Prescribing antibiotics is the mainstay of treatment for infections.

  • Intravenous. At first, your child will need to stay at the hospital to receive antibiotics through the veins (intravenous or IV). How long your child will stay in the hospital will depend on how severe the infection is. Most children with bone, joint, or muscle infections are in the hospital for 1 to 2 weeks.
  • Oral. For many children, the antibiotic is eventually changed to a form that can be taken by mouth (oral) and given at home.
  • PICC line. Some children can continue to receive an antibiotic by vein at home through a special intravenous device called a PICC (pronounced “pick”) line. This is a peripherally introduced central catheter (PICC).

The amount of time on antibiotics that is needed to resolve an infection varies from child to child but, in general, is 4 to 6 weeks for a bone infection and 3 to 4 weeks for joint or muscle infections.

It is very important to have your child take all of the antibiotics he or she is given, in exactly the way they are prescribed.

Surgical Treatment

In mild infections, antibiotics alone may resolve the condition. Many children, however, will need surgery to remove infected material (pus) from the area of infection. This will reduce pressure and inflammation and improve blood flow, which will make it easier for the antibiotics to reach the infected area. For most children, one surgical procedure is enough, but more severe infections may require two or more surgeries to help resolve the infection.

Infected biceps muscle

An infection in the biceps muscle has caused pus to accumulate in this child’s upper arm. During surgery, the pus will be drained so that antibiotics can effectively reach and resolve the infection.
Courtesy of Children’s Medical Center of Dallas

Outcome

Most children will completely recover from deep infections after proper treatment. They are not likely to develop the same infection again. In most cases, children have no further problems and return to all of their activities.

In general, children do better when the infection is recognized early. There is a greater chance for full recovery when the infection is quickly recognized and treated. The later the diagnosis is made, the more likely it is that the infection will cause greater damage to the bones, muscles and other tissues that are involved.

Some problems can occur in children who have serious and prolonged infections. These include blood clots, growth arrests, deformed bones, fractures through bone that is weakened from infection, bone death (called necrosis), and joint stiffness. However, these problems are rare.

Methicillin Resistant Staphylococcus Aureus (MRSA)

In many communities, deep infections are more frequently being caused by a particular type of bacteria known as MRSA. This bacteria is more able to resist antibiotics that previously worked well to treat these infections.

Currently, there are several antibiotics that work very well against MRSA and are tolerated very well by the children who are treated.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.