Journal of Orthopedics for Physician Assistants

Volume 1 | Issue 1
www.thejopa.org
Jopa
Journal of Orthopedics
for Physician Assistants
Review Articles
Lumbar Disc Herniation
Factors Influencing Antibiotic Choice
for Acute Osteomyelitis
Preoperative Decolonization of MSSA/MRSA
Nasal Carriage and the Effect on Orthopedic
Postoperative Surgical Site Infections
Nonoperative Treatment of Knee Osteoarthritis
Sideline Diagnosis and Management of
Sports-Related Concussions
Case Studies
Osteoid Osteoma
Procedures in Orthopedics
Fluoroscopic Hip Injections
Professional Issues and Experiences
Combat Orthopedics
PA Owned and Operated
Compliments of
A Journal
Created for Physician
Assistants in Orthopedics
JOPA 1
Journal of
Orthopedics for Physician Assistants
Journal Mission
Contents
The Journal of Orthopedics for Physician
Assistants (JOPA) is an academic resource created to
deliver ongoing orthopedic education for physician
assistants. The journal is a unique forum to share
our knowledge and experiences with colleagues in
the profession. JOPA strives to publish timely and
practical articles covering all subspecialties. Each
article is peer reviewed to ensure accuracy, clinical
relevance, and readability.
4
5
Dagan Cloutier, PA-C, Editor in Chief
BioScience Writers LLC
(www.biosciencewriters.com), Content Editor
Ryan Ouellette, Webmaster, thejopa.org
Spectrum Marketing, Journal Design
14
Message From the Editor
Osteoid Osteoma
Case Study One
Case Study Two and Discussion
10
Combat Orthopedics
My Experience During Operation
Enduring Freedom
13
Image Quiz
Hip Radiograph Interpretation
Procedures in Orthopedics
Fluoroscopic Hip Injections
16
22
Lumbar Disc Herniation
Normal/ Abnormal Image Review
Rotator Cuff Tears
24
Writing for JOPA
Information for Authors
Physician Assistant
Review Board
Brian Barry
Portsmouth, NH
Ryan Brainard
Savannah, GA
Afton Branton
Geneva, NY
Mark Carbo
Alexandria, LA
Ray Carlson
San Diego, CA
Jeff Chambers
Athens, Georgia
Larry Collins
Tampa, FL
Charles Dowell
Vancouver, WA
Caitlin Eagen
Boston, MA
Erich Fogg
York, ME
Bruce Gallio
Reno, NV
Jennifer Hart
Charlottesville, VA
Jennifer Hartman
Peoria, AZ
Michael Harvey
Fishers, IN
Sean Hazzard
Boston, MA
Tim Holstrom
Pullman, WA
Mike Houle
Hartford, CT
Angela Grochowski
Horsham, PA
Alan Johnston
Nashua, NH
Stuart Jones
Brentwood, TN
Stanley J. Kotara
Lubbock, TX
Kathleen Martinelli
Durham, NC
Patrick McCarthy
Manchester, NH
Terry Mize
Atlanta, Georgia
Randall Pape
USAF Academy, CO
Keith Paul
Greensboro, NC
Robert B. Rogan
Johnson City, TN
Bradford Salzmann
Ware, MA
Steve Steiner
Manchester, NH
Timothy Thompson
Naples, FL
Mary Vacala
Savannah, GA
Marcos Vargas
Flushing, MI
Scott Walton
Caribou, ME
25
26
Test Your Knowledge Quiz
Infectious Disease Consult
Factors Influencing Antibiotic Choice
for Acute Osteomyelitis
29
33
36
40
Preoperative Decolonization
of MSSA/MRSA Nasal Carriage
and the Effect on Orthopedic
Postoperative Surgical Site
Infections
PA Owned and Operated
Nonoperative Treatment of Knee
Osteoarthritis
Physical Therapy Corner
The Graston Technique
41
Sideline Diagnosis and
Management of Sports-Related
Concussions
This issue is presented to you by:
Disclaimer: Statements and opinions expressed in articles
are those of the authors and do not necessarily reflect those
of the publisher. The publisher disclaims any responsibility
or liability for any material published herein. Acceptance of
advertising does not imply the publisher guarantees,
warrants, or endorses any product or service.
2
JOPA
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JOPA 3
Message from the Editor
This is an exciting time to be part of a growing profession as a physician assistant. PAs continue to emerge
as a solution for high-quality, affordable care. As our profession grows, further emphasis will be placed on
specialty recognition. The NCCPA recognizes orthopedics as one of five specialties deserving of a certificate
of added qualifications program. In the future, our profession should consider developing a specialty-focused
PANRE exam, particularly since many of us practice in the same specialty for our entire career. As PAs in
orthopedics, we can further distinguish our specialty by creating a publication that promotes an orthopedicfocused education. Publications for physician specialties have existed for many years, and the time has come
for the PA profession to develop specialty-based publications as well.
After we graduate PA school, many of us are inadequately prepared to work alongside resident- and
fellowship-trained orthopedic surgeons. The didactic phase of most PA programs focuses little on orthopedic
education, and a great deal of training occurs in clinical practice. Furthermore, most PAs choose to work in
surgical subspecialties without the opportunity to develop a general orthopedic education. When I started
at my practice 5 years ago, I quickly realized the substantial learning curve that myself and all new graduates
face and for a long time my only goal was to keep my head above water. The more seasoned PAs in the
practice saw patients independently and were treated as colleagues by our supervising physicians. This
independence was earned by accruing enough knowledge and experience to make most patient care decisions
independently. Like many PAs starting their careers in orthopedics, I was eager to learn and gain the respect
of my supervising physicians. I began to understand how important continuing education is in our field. As
my knowledge and experience grew, so did the mutual respect of my colleagues. Expanding my orthopedic
knowledge has improved my ability to provide high-quality patient care.
A publication our colleagues can contribute to and share
will help us all grow academically and further recognize our
specialty. The Journal of Orthopedics for Physician Assistants
(JOPA) will promote a focused orthopedic education. JOPA
strives to publish timely, clinically relevant, and readable
content across all subspecialties. With the help of industry
sponsors, JOPA has the potential to reach every PA practicing
in orthopedic surgery. This is an exciting opportunity to create
the first representing journal and unique academic resource
for our colleagues. As we advance our knowledge, our patients
and supervising physicians will further recognize the high
level of care we provide. The success of JOPA will depend
on contributions from others. Please visit our website (www.
thejopa.org) or e-mail me at [email protected] for further
details. I thank everyone who contributed to the first issue of
JOPA. Your effort made the journal a reality.
Dagan Cloutier, PA-C JOPA Editor in Chief
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Osteoid Osteoma
Case Study One
Sean Hazzard, PA-C, Kevin Raskin, MD, and Peter Asnis, MD
Massachusetts General Hospital, Boston, MA
A 19-year-old male presented to our sports
medicine clinic with the chief complaint of right
knee pain after an injury that occurred 9 months
earlier. He was snowboarding when he went off a
jump and miscalculated the landing, plummeting
approximately 20 ft before landing on the ground.
The patient did not fall down on impact, but landed
the jump upright on the board. He denies feeling a
“pop” or experiencing immediate swelling, but did
have pain along the medial aspect of the tibia. He
continued to snowboard a few more runs that day.
The patient stated that he was sore for a
week or two, but was bearing weight with minimal
problems. One month after the injury, the pain
began to increase without re-injury. He did not seek
medical attention until 3 months after the injury.
He was seen by another physician who obtained
an MRI and was diagnosed with a subacute tibial
plateau fracture. No other MRI abnormality was
noted. The patient was placed in a long leg cast
for 4 weeks before a follow-up MRI was obtained,
showing unchanged findings. The patient was then
placed in a hinged brace for 6 weeks.
FIGURE 1
He continued to have pain throughout
this time during any type of weight bearing. His
orthopedist provided a cortisone injection in the
pes anserine bursa, but no alleviation of the pain
resulted. Physical therapy was prescribed and
performed, with no improvement.
The patient was seen in our office for the first
time 9 months after his injury, with complaints
of generalized pain near the medial aspect of the
proximal tibia with any amount of weight bearing.
He could not return to strenuous activities. He
denied swelling, buckling, locking, giving way,
fever, chills, or sweats.
Examination
The patient walked with a normal gait
pattern. He was 5’9” and weighed 159 lbs. His knee
had a neutral alignment, no effusion, normal skin,
and no atrophy. His range of motion was 0-135
degrees with no pain exacerbated throughout this
range. No medial or lateral joint line tenderness
was found. Tenderness over the medial aspect
of the proximal tibia near the area of the pes
FIGURE 2
JOPA 5
anserine bursa/medial tibial metaphysis was found.
The extensor strength was 5/5. The knee was stable
to Lachman, pivot shift, and anterior and posterior
drawer tests, as well as varus/valgus stress testing at
0 and 30 degrees. A dial test was also negative at 30
and 90 degrees. The patient’s neurovascular status
was intact.
Radiographs of the right knee were taken the day
of the exam and revealed that the joint spaces were
well maintained. Radiographs showed 8-mm lucency
in the right proximal tibial metadiaphysis with
overlying mature periosteal new bone formation and
thin reactive sclerotic borders, as well as a sclerotic
central nidus (Figures 1 and 2).
During the patient’s visit, the previously taken
MRI films were not available, but radiology reports
from the previous studies were. The first MRI was done
3 months post-injury and demonstrated extensive
patchy and linear marrow edema throughout the
medial proximal tibia crossing the fused physis.
These observations were consistent with a subacute
fracture extending to the tibial spine. The second MRI
study was done 4 months post-injury and revealed
a stable nondisplaced fracture of the proximal tibia
with patchy edema throughout the proximal tibia,
which did not substantially change from the original
study. After we reviewed our radiograph findings,
we referred the patient to an orthopedic oncologist,
who obtained a subsequent MRI with contrast. The
results were most consistent with an osteoid osteoma
(Figures 3 and 4).
FIGURE 3
Treatment
Treatment included radiofrequency ablation.
Under CT guidance, a needle biopsy is performed,
followed by introduction of a radiofrequency
electrode through the biopsy hole, within the lesion,
and heating of the tumor to 194°F for 6 consecutive
minutes.
Three weeks after the procedure, the patient
was asymptomatic and expected to return to
snowboarding within the coming weeks. He was
able to resume full activities. Additional follow-up is
pending.
Authors have no relationship to disclose relating to the
content of this article
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FIGURE 4
Osteoid Osteoma
Case Study Two and Discussion
Charles Dowell, PA-C, AT-C
Rebound Orthopedics, Vancouver, WA
A 65-year-old female presented to the
orthopedic clinic with a 6-month history of right
low back, gluteal, and thigh pain. The patient is
a nurse in an OB-GYN unit and gradually noticed
increasing pain in the right leg. She described
no history of injury or fall. She presented to the
emergency room 2 months after the onset of pain
for radiographs, which were read as negative. She
was referred to a physiatrist, who repeated the
radiographs (Figure 1), which were also read as
negative.
The physiatrist felt that the pain was radiating
from her lumbar spine, and ordered an MRI of the
lumbar spine and a bone scan. The MRI of the
lumbar spine showed some facet joint arthritis
at L4–L5 and L5–S1 on the right side. The bone
scan was read as a possible stress fracture of the
proximal lateral femoral cortex. Therefore, the
patient was diagnosed with a stress fracture and
told to remain non-weight bearing. The physiatrist
gave the patient a prescription for NSAIDs, which
she stated did improve her symptoms slightly,
although the pain returned.
FIGURE 1
The pain significantly affected the patient’s
daily activities as well as work. The pain was
worse with standing and walking activities, and got
progressively worse throughout the day. She also
complained of night time symptoms that regularly
woke her from sleep. The patient progressed to
the point where she had to take time off work and
began using crutches. She was referred to our
orthopedic clinic at this stage.
Her
examination
exhibited
palpable
tenderness directly over the posterior superior
iliac spine and posterior sacroiliac joint, extending
through her posterior ileum and iliac wing. The
tenderness extended into the posterior gluteal
and lateral greater trochanteric areas. She had
increased pain with trunk flexion/extension and
rotation to the right side. Passive range of motion
of her hip with log roll, hip flexion, internal/
external rotation, and abduction/adduction did
not cause pain. Resistive range of motion did cause
pain with flexion and abduction against resistance.
She had a negative straight leg raise. Her calves
were soft and nontender, and she had a normal
FIGURE 2
neurovascular exam. Increased pain was elicited
with any attempt to bear weight on the right side
with single and double leg stances.
This patient had an unusual presentation for
a stress fracture, and her exam was inconsistent
with this diagnosis. The radiographs did not show
the typical transverse line seen in the area of
cortical thickening that is consistent with a stress
fracture. For this reason, she was sent for a CT scan
(Figure 2) and an MRI (Figure 3) of her right hip and
thigh. The results of these tests were inconclusive,
JOPA 7
FIGURE 3
as the radiologist read the MRI consistent with a
stress fracture and the CT scan consistent with
an osteoid osteoma. After discussion with our
musculoskeletal radiologist, it was decided that
MRI, CT, and bone scan were most consistent with
an osteoid osteoma. With this unusual presentation
and failure of non-surgical treatment, the patient
was referred to an interventional radiologist for CTguided radiofrequency (RF) ablation. At the time of
this article, the patient had not followed up with
the interventional radiologist.
Discussion
Osteoid osteoma is the most common benign
bone-forming lesion and was first characterized by
Jaffe in 1935. 1,2 It is the third most common benign
bone neoplasm after osteochondroma and nonossifying fibroma,2 which most commonly occurs
in persons aged 5–25 years, with a male:female
ratio of 2:1. Its elective sites are the long bones,
especially the femur and tibia, which are involved
more than 50% of the time. Depending on their
locations within the bone, osteoid osteomas can
be distinguished into cortical (70–75% of cases),
medullary (25% of the cases), subperiosteal, and
intra-articular.4
The lesion is usually less than 1.5 cm in
diameter and contains a discrete central area
8
JOPA
known as the nidus, which is surrounded by dense
sclerotic bone tissue.3 The nidus is composed of
thin seams of osteoid or woven bone lined with
osteoblasts, which represents a process of bone
remodeling with osteoblastic activity.3 The nidus is
surrounded by a region of active bone formation
that appears as sclerotic dense bone with various
patterns of maturation.3 The nidus has been shown
to be highly vascularized and contain abundant
nerve fibers.2,4 These nerve fibers belong to the
osseous nerve supply, which plays an important
role in skeletal development and homeostasis.2
Osteoid osteomas usually present with a significant
amount of soft tissue swelling around the area
affected, and this may be secondary to the highly
vascular nature of the tumor.2 Swelling may be
mediated by production of prostaglandins, which
can affect soft tissue and vascular permeability.2
Prostaglandin levels in the nidus are 100–1,000
times that of normal bone and are thought to be
important in the perception of pain.2 The pain relief
associated with NSAIDs has also been attributed to
the inhibition of such prostaglandin production.2
Typical presentation includes localized pain
that is frequently more severe at night. The pain
may occasionally be relieved by NSAIDs. Depending
on the location of the lesion, patients may also
present with gait disturbances, bony deformity,
joint stiffness or contracture, growth disturbances,
swelling, and limb length discrepancies.2,3 In the
case of limb length discrepancies, it was found that
the involved extremity was typically the longer
one.3 One possible explanation for limb overgrowth
in children may be the resulting inflammatory
response and associated hyperemia, especially in
patients with lesions located near the open growth
plate.3
Osteoid osteomas in complex sites such as the
pelvis, posterior vertebrae, femoral neck, or hind
foot can be difficult to diagnose radiographically.4
The classic finding on conventional radiography is
an oval or round lucency (representing the nidus)
with or without calcifications, surrounded by bone
sclerosis and periosteal bone neoformation to
different degrees.4 Bone scintigraphy demonstrates
increased radionuclide uptake by the nidus.4 CT
remains the method of choice to diagnose and
locate the osteoid osteoma nidus, especially in
complex anatomical sites.4 The characteristic
appearance on a thinly sliced CT scan is of a lowattenuation nidus with central mineralization
and varying degrees of sclerosis surrounding
the nidus.3 A recent report recommends the use
of non-ionizing imaging modalities in children,
although the role of MRI remains controversial.2
The appearance of the lesion on MRI may be
highly variable, and the presence of associated
soft tissue changes and bone marrow edema may
result in diagnostic errors.3
Management is typically begun with
salicylates or NSAIDs because of the abovementioned control of prostaglandins and pain
relief. The time until symptoms subside with
treatment using just these medications can vary
from several months to several years. Surgical
management may be warranted if the pain is too
severe, the patient is unresponsive to medication,
or the patient is unwilling to wait for the symptoms
to spontaneously subside.
Until the late 1990s, open excision with removal
of the complete nidus was the only surgical option
available.3 This was found to be highly effective,
but sometimes the tumor was difficult to identify
intra-operatively, and incomplete resection could
result in recurrence.3 This method followed by a
prolonged period of weight-bearing restriction if
performed in one of the weight-bearing bones.
CT-guided percutaneous resection, a less-invasive
method, is performed with CT guidance to
minimize the amount of excised bone and ensure
that the entire nidus is resected.2 This is typically
an outpatient procedure, but may require an
overnight stay at the hospital. It is usually followed
by restriction of activities for 4 weeks with toetouch weight-bearing if performed on one of the
weight-bearing bones.
RF ablation has been used successfully to
treat osteoid osteomas for more than 20 years
and is currently the choice of treatment for most
lesions.2,3 RF ablation is performed with the use of
CT guidance, and the entire procedure generally
takes 90 min.3 The RF electrode is inserted with
the tip directed toward the nidus and thermal
heating is applied for 4–6 min.2,3 The success rate
for this procedure has been documented as high
as 90%, only requires a brief recovery, and has a
low complication rate.3
Conclusion
Osteoid osteoma can be a challenging
diagnosis if the patient does not present with
classic symptoms. A differential diagnosis can
include chronic osteomyelitis, stress fracture, nonspecific synovitis, arthritis, osteoblastoma, fibrous
dysplasia, melorheostosis, or Ewing’s sarcoma.4
Diagnosis can be even more confusing, such as in our
patient, with a presentation outside the typical age
group and a non-specific appearance on bone scan
and MRI. CT scan remains the modality of choice to
diagnose the lesions and the characteristic nidus.
Patients who appear with the typical throbbing pain
that is worse at night and responds to NSAIDs can
obtain a straight forward diagnosis. Currently, the
treatment of choice remains CT-guided RF ablation,
which has the highest success rate with the lowest
recovery time and rate of complications.
The author has no relationship to disclose relating to the
content of this article
References
1. Shankman S, Deasai P, Beltran J.Subperiosteal osteoid osteoma:
radiographic and pathologic manifestations. International Skeletal Society.
1997;26(8):457-62.
2. Laurence N, Epelman M, Markowitz R, et al.Osteoid osteomas: a pain in the
night diagnosis. Pediatric Radiology. 2012;42(12):1490-1501.
3. Atesok K, Alman B, Schemitsch E, et al. Osteoid Osteoma and
Osteoblastoma. J Am Acad Orthop Surg. 2011;19(11):678-689.
4. Cerase A, Priolo F.Skeletal benign bone-forming lesions. European Journal
of Radiology. 1998;27:S91-S97.
Clinical Pearl
Scapholunate advanced collapse (SLAC) is the most
Sc
common form of arthritis in the wrist. A wrist injury
co
causing scapholunate instability can lead to progressive
ca
degenerative changes and a SLAC wrist.
de
JOPA 9
JOPA
Combat Orthopedics
My Experience During Operation Enduring Freedom
Major Randall A. Pape, USAF
PA-C
“Level one trauma in the ED,
level one trauma in the ED, three
patients.” This is what I heard for the
past 6 months during my time spent
at Craig Joint Theatre Hospital (CJTH)
in Bagram Airfield, Afghanistan. I was
very fortunate to use my training and
experience as a physician assistant in
orthopedics caring for our wounded
warriors. I have been on active duty for
20 years and was lucky enough to be
Major Randall A. Pape outside Craig Joint Theatre Hospital
selected for the Interservice Physician
Assistant program 14 years ago. After
graduation, all PAs are commissioned as officers in
facilities being in the more dangerous areas. We
the Air Force and placed in primary care jobs. To
received indirect fire in Bagram several times per
specialize, PAs must apply to a very competitive
month, and each time caused the alarm to sound
board that meets once per year. After selection,
and required everyone to don individual body
PAs must complete a year-long fellowship before
armor.
being placed into a job using the new training. Upon
The top priority of our medical team was to
notification of a free, all expenses-paid trip to the
respond to and care for wounded warriors. Most
Middle East, there is more training to complete.
patients arrived via Blackhawk helicopter or were
Not only is there job-specific training, including a
transferred in on a fixed-wing aircraft (military
refresher course on trauma, but PAs must be replane). The wounded were initially cared for by
qualified with their weapon(s) and on how to don
their co-workers based on training they received
a chemical suit and gas mask.
prior to deploying. Many limb-saving tourniquets
Here, I hope to provide a glimpse of what
are applied in the field. The wounded are then often
my job entailed in a combat setting. As the sole
stabilized at a Role II facility manned by a general
PA in orthopedics at CJTH, I had many duties
surgeon, an orthopedic surgeon, an anesthesia
and responsibilities. These included responding
provider, an OR nurse, and a surgical technician.
to trauma calls, being the first assistant in the
The current survival rate of all patients who reach
operating room, participating in daily rounds,
CJTH is an astounding 98.6%.
daily meetings, and weekly Afghan clinics, which
Patients entered the trauma bay from the flight
included caring for enemy prisoners, and being online through Warrior’s Way with an American flag
call 24/7 for 6 months.
draped across the ceiling. This was our way of
CJTH is one of three Role III facilities in
letting these patients know that they were entering
Afghanistan. Two of these facilities are run by the
an American facility. Here, they were immediately
U.S. military and one is run by the British military.
evaluated by the emergency department provider,
CJTH is unique in that it is the hub of aero-medical
either an emergency room doctor or an ER PA, and
evacuation; therefore, all of the troops that are to
a trauma surgeon. We evaluated the orthopedic
be evacuated through the aero-medical evacuation
injuries and triaged the patients for surgery. The
system come through CJTH in Bagram. All of the
orthopedic team consisted of three orthopedic
hospitals are in the combat zone with the Role II
surgeons, one orthopedic surgical technician, and
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JOPA
AmbuBus delivering patients to the
Emergency Department via Warriors Way
me. As the orthopedic PA, I was responsible for
working with the trauma surgeon to determine the
order of patients based on severity of injury. Our
orthopedic team would then divide and conquer,
either with each of us working on a single patient
or each of us taking an injured extremity on a
single patient. This process was determined by the
number of patients presenting during the trauma
call.
CJTH had three ORs, and each OR had the
ability to serve two patients. This allowed us to
take multiple patients into the OR at one time.
The surgeries ranged from the all-too-common
slamming of a hand in a mine-resistant ambush
protected vehicle door, which weighs 900 lbs, to
multiple limb amputations on a single patient. The
multiple limb amputations usually occurred in the
younger soldiers and marines, with the majority of
such patients in their early 20s. We had one triple
amputee who was a 4-year-old local national. He was
playing on an improvised explosive device (IED)
that his uncle had brought home when it exploded.
Many of our patients required simultaneous care by
providers in general surgery, urology, and vascular
surgery. We were able to work together on the
patient, always trying to stay out of each other’s
way, or helping when required. I found myself
often retracting for the general surgeon or cutting
sutures for the urologist.
Many of the patients for whom we cared were
injured by a blast mechanism. My experience in
Afghanistan was much different from my experience
in Iraq; many of our injuries in Afghanistan were
dismounted (on foot) when injured by IEDs as
opposed to mounted (in a vehicle) in Iraq. The
dismounted IED injury wreaks havoc on the
remaining soft tissues because the blast pattern
carries the debris well up into the soft tissue. This
injury requires a long and tedious debridement of
the remaining soft tissue to help prevent infections.
These patients often developed fungal infections
that were very difficult to treat. It was not uncommon
for these individuals to lose both lower extremities
above the knee and a hand or some fingers on the
lead arm that had carried the forward portion of
their rifle. It was our job to meticulously clean
these wounds and stabilize any fractures, usually
with external fixators. Depending on the number
of patients and the number of extremities that
were injured, PAs were often responsible for the
care of a single extremity, including application of
external fixators . During my 6-month rotation, we
operated on over 700 patients and more than 1,300
extremities. PAs in the deployed setting have more
autonomy than those stationed in the states. Such
PAs are required to do what it takes to help save
lives and care for patients. Depending upon where
a PA is stationed, the PA may be the patient’s only
chance for survival.
We refrained from implanting any hardware that
would remain in the patient due to the increased
risk of infection in Afghanistan. Wounds were either
covered with negative-pressure dressings (wound
vacuum-assisted closures, or VACs) or placed in
special dressings that were soaked with Dakin’s
solution periodically if a wound was at increased risk
for fungal infection. After stabilization and recovery
IED Blast injury to the foot
JOPA 11
in the intensive care unit (ICU) or ward, patients
were sent to Germany through our aero-medical
evacuation system. From Germany, patients would
move on to a large medical treatment facility near
where they lived in the U.S.
My other responsibilities consisted of lessthan-glamorous daily rounds and morning meetings.
After our patients left the OR, they were signed
out to either the ICU or ward. We were in constant
communication with the physicians assigned
to these areas. I was the point of contact for any
questions regarding the orthopedic care of the
patients in the ICU or ward . It was my responsibility
to change dressings and fix any dressing problems,
such as wound VAC troubleshooting, when
necessary. The physicians and PAs met every
morning to discuss the in-house patients and what
their projected patient movements were. After
the morning meeting, we visited each patient,
discussing past and future care for each person.
This was very important for our local national
patients, whether they were Afghan National Army,
Afghan National Police, or civilian patients . We got
instant feedback about whether we were going to
be able to care for each patient definitively or they
were to be transferred to another facility. We also
received updates on patients’ overall health and
nutritional well-being. The majority of our Afghan
patients were malnourished, which made for very
difficult wound healing.
communicating with the prisoners because the
interpreters stood behind a curtain so that they
could not be identified and targeted later by these
individuals.
I was responsible for running the orthopedic
service at CJTH. The teamwork in the combat
setting was unparalleled, with all team members
focused on getting the patients out of the OR as
quickly and safely as possible so they could begin
their long journey home. Keeping the surgeons
available for the OR was of the utmost importance.
Although this meant taking on all of the grunt
work of meetings, rounds, dressing changes, and
clinics, I believe there is nothing more rewarding
professionally than caring for our nation’s wounded
warriors. Hippocrates said, “He who wishes to be a
surgeon should go to war.” After three trips there, I
truly know what he meant.
The author has no relationship to disclose relating to the
content of this article
PAs were available, traumas permitting, for
consultation on non-traumatic injuries. During
my rotation, we were fortunate to have a sports
medicine-trained family practice physician who
handled most of these consultations, but some of
the other deployed orthopedic PAs dealt with such
consultations personally.
CJTH also saw local nationals upon whom
we had operated for follow-up 1 day per week.
All communication with the local nationals was
done through an interpreter. We often wondered if
we were being told what the patient was actually
saying or what the interpreter thought we wanted
to hear. Usually, the same afternoon was spent
evaluating consultations from the Afghanistan
prison located in Bagram, which included many
unusual cases, such as a prisoner who had the
tip of his finger bitten off by another prisoner for
pointing at the other prisoner and telling him to sit
down and be quiet. It was even more of a challenge
12
JOPA
In Memory of Jerry “Buck” Pope
October 1967 - October 2002
Husband, Father, Friend, Classmate died while deployed in Yemen
Share your Experiences with JOPA
The Journal of Orthopedics
for Physician Assistants (JOPA)
provides a unique forum for sharing
ideas and experiences with your
colleagues. JOPA is the first journal
representing the physician assistant
orthopedic specialty and unique
voice for all in the profession. We can
all learn and grow from our shared
experiences.
Image Quiz
A 74-year-old female with a history of left-sided cerebrovascular accident presented to the emergency
department with a 2-day history of left hip pain. She fell at home 2 days previously and chose not to seek
medical attention initially because she thought the pain would improve. The patient lives with her son, who
brought her to the emergency department for evaluation.
FIGURE 1. AP radiograph of the left hip
FIGURE 2. Frog leg lateral radiograph of left hip
Based on the radiographs above, what would be the next best
choice of treatment for this patient?
A.
B.
C.
D.
Open reduction-internal fixation
Intramedullary short nail
Obtain a CT or MRI to check for occult fracture extension
Nonsurgical: partial weight-bearing, 6 to 8 weeks
Answer on page 21
JOPA 13
Procedures in Orthopedics:
Fluoroscopic Hip Injections
Alan B. Johnston, PA-C
New Hampshire Orthopaedic Center, Nashua, NH
Osteoarthritis of the hip is a common condition seen in most orthopedic practices. Other conditions
such as femoro-acetabular impingment (FAI), labral tears, synovitis, and conditions affecting the lumbar
spine can mimic hip arthritis. Various methods of treatment are available for these conditions, ranging from
observation to surgical management. Our practice uses fluoroscopically guided intra-articular injections as
an invaluable treatment option.
With the addition of onsite magnetic resonance imaging (MRI) services to our practice several years
ago, we researched and developed techniques to provide arthrography of the hip in conjunction with MRI.
The options have since expanded to include intra-articular steroid injections for osteoarthritis and synovitis,
aspirations for infection, and diagnostic injections to differentiate between intra-articular and extra-articular
conditions, as well as injection techniques for the shoulder, elbow, wrist, ankle, and sacroiliac joints.
With regard to the hip, the indication for intra-articular injections is short-term relief of pain, most
commonly in the arthritic patient who is unwilling or unable to undergo arthroplasty. Contraindications
for the procedure include allergies to contrast material, injectable anesthetics, or steroids. Relative
contraindications include use of anticoagulation medications. Patients who are on aspirin therapy may
proceed with intra-articular injection treatment. Patients taking other anticoagulants, including warfarin,
clopidogrel, dabigatran, and the like, should stop use of the anticoagulant 5 days before the intra-articular
injection procedure, if medically appropriate. Diabetic patients are cautioned about possible elevation of
their blood sugar levels and are advised to adjust their medications accordingly.
PROCEDURE
The patient dresses in a gown, with the opening
toward the back. The patient is then placed supine
on a radiolucent table. A bolster is placed under the
ipsilateral knee to flex the hip. If the patient’s leg is
in any external rotation, the feet are taped together
to internally rotate the hip and provide a better
image of the femoral neck. The anterior aspect of
the hip is exposed and prepared with betadine and
alcohol. After palpating the patient’s femoral artery,
a sheathed needle is placed superior and lateral to
the artery. The image intensifier is used to locate the
injection entry site by adjusting the needle so that
the tip of the needle is overlying the junction of the
lateral femoral head and neck (Figure 1). The area is
marked and the skin and subcutaneous tissues are
injected with 5 ml 1% plain xylocaine.
After satisfactory anesthesia is achieved, a
22-gauge spinal needle is introduced into the hip under
direct fluoroscopic guidance. The needle is advanced
parallel to the x-ray beam and perpendicular to the
floor. It is imperative to keep the needle as parallel
14
JOPA
FIGURE 1
Procedures in Orthopedics:
Fluoroscopic Hip Injections
to the beam as possible to avoid losing orientation.
As the needle is advanced, some resistance will
be met as it approaches the anterior hip capsule.
The patient is warned that he or she may feel some
mild discomfort as the needle is advanced through
the capsule, especially patients with inflammatory
conditions within the hip joint.
As the needle is advanced through the
capsule, contact should be made with the lateral
femoral neck (Figure 2). Extension tubing is
attached to the spinal needle, and contrast material
(5 ml Isovue300 and 4 ml saline) is injected into
the hip to confirm position. The needle should be
stabilized during the injection to prevent it from
being expelled from the hip joint by the inflow of
fluid. A characteristic intra-articular filling pattern
should be noted (Figure 3), and only the amount
of contrast material needed to confirm position is
used.
FIGURE 2
After intra-articular position is confirmed on
the image intensifier, the needle is left in place with
the extension tubing attached. The contrast syringe
is removed and a syringe containing 6 ml 1% plain
xylocaine and 80 mg Depo Medrol is injected slowly
into the hip. The spinal needle is withdrawn, and
a bandage is applied to the injection site after any
bleeding is controlled.
Post-injection instructions are given to the
patient prior to departure from the fluoroscopy
suite. Patients are advised that they may experience
a sensation of fullness or mild discomfort
secondary to capsular distention, which usually
resolves after several minutes, and are also advised
to limit unnecessary ambulation for 24–48 hours
to avoid undue discomfort. Ice can be used at the
injection site for local soreness from the needle
puncture. Diabetic patients are again cautioned
about possible elevation of blood sugar levels and
advised to adjust their medications accordingly.
Patients are seen back in the office
after approximately 6 weeks for re-evaluation
to determine their response to the injection. If
successful, the injection may be repeated three to
four times a year, so long as it remains effective.
FIGURE 3
SUMMARY
In summary, intra-articular steroid injection
with fluoroscopic guidance is an effective treatment
option for various pathologies involving the hip.
The technique is relatively safe and easy to master,
and very well tolerated by the patient. To date, no
infections, bleeding issues, or neural injuries have
been reported at our facility, and we continue to
perform these injections on a daily basis.
The author has no relationship to disclose relating to the
content of this article
JOPA 15
Lumbar Disc Herniation
Dagan Cloutier, PA-C
New Hampshire Orthopaedic Center, Nashua, NH
Travis Palmer, PA-C
New Hampshire NeuroSpine Institute, Bedford, NH
Lumbar disc herniation is the most common
surgical condition in patients presenting with
radicular leg pain, with approximately 200,000
patients undergoing operative treatment each
year.1 Lumbar herniated nucleus pulposus (HNP)
presents symptomatically with a sudden or
insidious onset of unilateral leg pain and is usually
associated with an injury or precipitating event
(often a forward bend and lifting maneuver, during
which intradiscal pressure is high). Patients may
also complain of intermittent back pain for months
or years, with a recent aggravating event that
worsens symptoms.
Radicular pain usually extends below the
knee and follows a dermatomal pattern, correlating
with the nerve root involved. With lumbar disc
herniation, symptomatic leg pain is more severe
and frequent than low back pain. Standing,
prolonged sitting, and Valsalva maneuvers can
aggravate the pain. Lumbar HNP usually affects
young and middle-aged adults, with a peak in those
35 to 45 years of age. As the nucleus pulposus ages,
it loses water content and desiccates, and is less
likely to herniate after the fifth decade of life.
younger adults are well hydrated and more likely
to herniate. Lumbar roots below L1 are contained
within the cauda equina and exit the neural foramen
under the corresponding pedicles. For example, the
L5 root traverses below the L4–L5 disc level and
exits laterally under the pedicle of L5. The S1 nerve
root traverses below the L5–S1 disc level and exits
laterally under the pedicle of S1.
Disc herniation can be classified by location
into three anatomical zones of the spinal canal:
central, paracentral, and foraminal. The central zone
lies between the lateral borders of the cauda equina.
The paracentral or posterior lateral zone extends
from the lateral border of the cauda equina to the
medial border of the pedicle. The foraminal zone
lies between the medial and lateral borders of the
pedicle. Extraforaminal disc herniations are located
lateral to the border of the pedicle. Posterior to the
disc space is the posterior longitudinal ligament
(PLL). The PLL is an hourglass-shaped ligament, with
the widest part located at the midline and thinning
bands extending laterally. The superior lateral disc
is left uncovered by the PLL, which explains why this
location is the most common site of disc herniation.
The location of the disc herniation will
determine which nerve root is affected. Posterior
lateral disc herniations generally affect the nerve
Anatomy
Intervertebral discs are comprised of the
nucleus pulposus, a firm, rubbery tissue that is
surrounded by the ligamentous anulus fibrosus.
Axial compression forces are transmitted to the
nucleus and sustained circumferentially by the
anulus. The nucleus pulposus lacks blood supply
and nerve innervation, and relies on nutrients
and oxygen that diffuse from the anulus fibrosus.
Consequently, any injury to the nucleus pulposus
will not heal.
The anulus contains nerve innervation and
may cause lower back pain with injury. The anulus
also contains a blood supply that allows scar
formation and healing after injury. Any disruption
of the anulus can result in herniated disc tissue due
to axial compression forces of the spine. Discs in
16
JOPA
FIGURE 1 Posterior Longitudinal Ligament.
The red oval shows the location of a posterior
lateral disc herniation.
Table 1. Exam findings in Lumbar Disc Disease
Level of HNP
L1-L3
L3-L4
L4-L5
Root affected
L2, L3
L4
L5
L5-S1
S1
Motor strength
Hip Flexors
Tibialis anterior
Extensor hallucis
longus
Gastroc/ Soleus
S2-S4
S2, S3, S4
Bowel/ Bladder
root at the traversing level. The less-common
lateral recess and foraminal disc herniations affect
the exiting nerve root at the affected level. For
instance, an L4–L5 posterior lateral disc herniation
would affect the L5 nerve root. A foraminal
herniation at that L4–L5 level would affect the L4
nerve root. The majority of herniations occur in
the L4–L5 and L5–S1 levels.
Pathology
Disc herniations can be classified as
protrusion, extrusion, or sequestered. Disc
protrusion (or disc bulge) is a symmetrical bulge
around the circumference of the anulus, leaving
the anulus intact. Disc protrusion may or may not
impinge on a neurologic structure. The resulting
pressure from the disc bulge on the innervated
anulus can cause a significant amount of lower
back pain, which is often referred to or diagnosed
as discogenic back pain. A disc extrusion extends
through an annular tear, but is still in partial
continuity with the parent disc. An annular tear
can cause significant back pain when it occurs,
but after the pressure is relieved, the back pain
usually subsides. A sequestered disc herniation
is a fragment free from the parent disc within
the spinal canal and prone to proximal and distal
migration, usually only 1 or 2 cm.
Spinal nerve root compression from HNP can
cause moderate to severe radicular pain, decreased
sensation, and motor weakness. However, nerve
root compression from the disc pathology is not
always symptomatic. Lumbar MRI commonly
reveals asymptomatic disc pathology. Fewer
than 6% of lumbosacral disc herniations become
symptomatic.2 Symptomatic herniations are not
always a result of direct neurologic compression.
Chemical nerve root irritation plays an important
role in radicular pain. Acute herniated disc material
triggers the release of arachidonic acid and other
Sensation
Anterior thigh
Medial ankle
Dorsum of foot
Reflex
None
Patella
None
Posterior calf, plantar
foot
Perianal
Achilles
Cremesteric
inflammatory mediators that encounter the nerve
root, causing irritation.1
Exam
Exam begins with observation of the
patient’s pain level and any postural changes. Pain
can worsen when disc space pressure increases
during activities like walking, sitting, and standing.
Lying reduces disc space pressure and usually
improves pain. The patient often cannot sit still
and constantly changes positions in an effort to
find a more comfortable position.
A complete neurological exam is necessary
and should include testing of lower extremity
motor strength, sensation, and reflexes. Muscle
group weakness may be evident at presentation or
several weeks after herniation occurs. Sensation is
decreased almost immediately along a dermatomal
pattern, correlating with the insulted nerve. Deep
tendon reflexes are often depressed or absent in
the affected muscle group. Provocative testing
should be performed last because it will likely
illicit pain. Straight-leg raise of the involved leg
and the uninvolved contralateral leg may both
illicit radicular pain. Radicular pain in the involved
leg with straight-leg raise of the uninvolved leg
is specific for herniation. Back pain alone with
straight-leg raise is not a positive finding. Clinical
findings of pain, decreased motor strength, and
sensation are correlated with the nerve root
affected (Table 1).
A vascular exam, including palpation of
dorsalis pedis and posterior tibialis arteries,
should be performed. Vascular and neurogenic
claudication can cause leg pain and reduced
walking capacity. Neurogenic claudication has a
gradual progression of symptoms compared to
lumbar HNP and is more often caused by spinal
stenosis and degenerative spondylolisthesis.
Patients with spinal stenosis often complain
JOPA 17
FIGURE 2
Sagittal view of L5-S1 disc herniation
of worsening pain with spinal extension and
significant relief with flexion, whereas herniated
disc patients have more pain with spinal flexion
and relief with extension.
Testing for ankle clonus and Babinski’s will
help rule out upper motor neuron pathology. Hip
and pelvic pathology can cause referred pain
to the back and lower extremities. Differential
diagnoses that should be considered include hip
osteoarthritis, iliotibial band syndrome, meralgia
paresthetica, inguinal hernias, and sacroilitis.
Obtaining a detailed history and performing a
complete physical exam of the hip and lower
extremities will help establish the diagnosis.
Antero-posterior and lateral radiographs
are initially taken to check for spondylolithesis,
fracture, and foraminal stenosis. MRI is the
diagnostic study of choice, as it clearly delineates
size, type, and location of a disc herniation. An
MRI can differentiate other causes of radicuar
pain, such as primary tumor or metastatic disease
and bony compression. Symptoms of night pain
or previous history of cancer should warrant
MRI, even in case of negative initial radiographs.
Computed tomography myelography can be used
when MRI is contraindicated, such as in patients
18
JOPA
FIGURE 3 Axial view of left posterior lateral
disc herniation
with pacemakers. This form of imaging is also
helpful in patients with prior spinal surgery with
instrumentation.
Gadolinium-enhanced
MRI
should
be
performed in patients with a history of previous
level surgery or when recurrent disc herniation
is suspected. Contrast enhancement helps
differentiate disc herniation from postoperative
scar tissue causing neural impingement.
Electromyography can help differentiate radicular
symptoms from peripheral neuropathy or upper
motor neuropathy. Any presentation of urinary
retention, urinary or fecal incontinence, saddle
anesthesia, and bilateral radicular symptoms
should raise concern of possible cauda equina
syndrome (CES).
Cauda equina syndrome (CES)
CES occurs in only 2% of lumbar HNPs
and is usually caused by a large central lumbar
disc herniation. The cauda equina includes the
peripheral nerve roots L1–S5 located within the
dural sac. Compression of these roots causes
symptoms of a lower motor neuron lesion, such
as muscle weakness, decreased sensation, and
decreased or absent reflexes.
Onset of symptoms can be rapid or slowly
progressive. Symptoms unique to CES include
perigenital, perirectal, or “saddle” anesthesia
and loss of bowel or bladder control. Bladder
dysfunction is a required symptom for diagnosing
CES. Motor loss can start with subtle difficulty
initiating the urinary stream with progression
to urinary retention and eventual overflow
incontinence. Decreased rectal tone can be an
early sign of CES, and a rectal exam is important
in establishing the diagnosis. Preferable treatment
is decompression via discectomy within 24 h of
symptoms to prevent progression of neurological
deficits. Although timing of surgery is still under
debate, evidence shows that there is a significant
difference in the resolution of motor and sensory
deficits postoperatively with treatment within 48
h.3
Treatment
Herniated lumbar discs affect 2% of the
population. Seventy-five percent of these patients
are asymptomatic after 6 weeks, and 90% are
symptom-free at 3 months . Resolution of motor
weakness is seen with 80% of patients after 6 weeks,
90% after 12 weeks, and 93% after 24 weeks.2
The natural history of lumbar disc herniation
is eventual disc resorption and resolution of
symptoms. Conservative care with rest and antiinflammatory medications are initiated early. A
Medrol DosePak, which can include a 6-day tapering
course of 4 mg methylprednisolone with six tablets
on the first day and one tablet on the last day, is
commonly prescribed. Patients should be advised
that there is less than a 10% chance of significant
symptoms beyond 3 months. Physical therapy
should be started to strengthen core muscles when
symptoms tolerate. Transcutaneous electrical
nerve stimulation (TENS) units are commonly used
in the therapy setting for pain relief. Narcotics and
muscle relaxers are used cautiously to prevent
dependence.
Lumbar epidural steroid injections (ESIs)
have increasingly been used as a low-risk
alternative to surgical intervention for patients
who failed conservative treatment. Steroids
inhibit the inflammatory response caused by disc
chemical irritation and mechanical compression.
Common injection techniques include interlaminal
and transforaminal approaches. Transforaminal
injections target the anterior epidural space
closest to the nerve root pathology. Interlaminal
injections deliver fluid into the posterior epidural
compartment, with hope that it will flow to the
insulted nerve root.4 Transforaminal approaches
require fluoroscopic guidance for safe and accurate
placement.
Butterman reported on the efficacy of
treatment with ESIs in surgical candidates with
lumbar disc herniation. Nearly one-half of the
patients who received ESIs had a decrease in
symptoms. The degree of improvement was
similar to the results seen in patients who
underwent discectomy. The study also reported
that delaying surgery for an initial trial period of
ESIs was not detrimental to neurological recovery.5
Contraindications for ESIs include local or systemic
infection, anticoagulation, contrast dye allergy,
and previous spine surgery at that level.
Spine Patient Outcome
Research Trial (SPORT)
The Spine Patient Outcome Research Trial
(SPORT) was a prospective, multicenter study
funded by the National Institutes of Health that
examined surgical vs. non-surgical outcomes for
intervertebral disc herniation, spinal stenosis, and
degenerative spondylolisthesis. SPORT was one of
the first comprehensive studies of the efficacy of
surgery for lumbar disc herniation. The variable
discectomy rates within regions of the United
States and the lower rates seen internationally
raise concern about the appropriateness of
surgical decision-making. SPORT was designed to
address these concerns and provide information
on how to best treat lumber disc herniation.
Candidates from 13 spine clinics across 11
states with image-confirmed lumbar disc herniation
were randomized into one of two groups: operative
treatment and non-operative treatment. Patients
included 501 surgical candidates with imageconfirmed lumbar disc herniation and persistent
signs and symptoms of radiculopathy for at least
6 weeks. Weinstein et al. reported that patients
in both the operative treatment group and nonoperative treatment group improved substantially
over a 2-year period. Due to the large patient
crossover between treatment groups, the intentto-treat analysis showed no statistically significant
JOPA 19
differences between the two groups. Although
not significant, differences in improvements were
consistently in favor of surgery for all outcomes
and at all time periods. The pattern of crossover
between treatment groups suggested the intentto-treat analysis underestimated the true effect of
surgery.6
In 2008, Weinstein et al. reported on results
between groups at 4 years. Patients who underwent
surgery achieved greater improvement than the
non-operatively treated patients in all primary and
secondary outcomes except for work status.7
Several other studies based on the SPORT data
have been published. Radcliff et al. investigated
the effect of ESIs on primary outcome scores and
how ESIs influenced operative vs. non-operative
treatments. Results showed no significant
differences in outcome scores between patients
who received ESIs and patients who did not at
years 1, 2, 3, and 4. However, the study showed an
increased rate of surgical avoidance in the group
who received ESIs. The study reported a 41% rate
of crossover by surgically assigned patients who
received ESIs, compared to a 12% rate of crossover
by surgically assigned patients who did not receive
ESIs.8
Rihn et al. examined symptom duration and
how timing of treatment influenced outcome. The
study concluded that increased symptom duration
beyond 6 months due to lumbar disc herniation
was related to worse outcomes for patients in
both the operative and non-operative groups. The
increased relative benefit of surgery compared to
non-operative treatment was independent of the
duration of symptoms.9
Operative Treatment
The main surgical indication for lumbar disc
herniation is unremitting radicular pain. Motor
weakness caused by lumbar disc herniation will
resolve in most cases and is not an indication for
surgery. Only when motor weakness is disabling
and associated with severe pain or progresses
rapidly is surgery indicated. There is no evidence
to support that surgery improves the recovery of
motor weakness better than conservative care in the
short-term or long-term. Residual motor weakness
postoperatively is correlated with the severity and
duration of motor symptoms preoperatively.2
20
JOPA
MRI will confirm the level and location of disc
herniation, which should correlate with the patient’s
physical signs and symptoms. Timing of surgery is
a source of ongoing debate. Paul et al. reported that
early surgery after a failed conservative treatment
period of 6 weeks offered significant benefits over
non-operative treatment in the early follow-up
period. The maximum surgical benefit was seen at
8 to 12 weeks postoperatively. However, at years
1 and 2, no differences existed between operative
and non-operative groups in primary outcome
measures.10 Therefore, patients should be educated
on the benefits of surgery in the short-term, as longterm benefits are less proven. A patient’s treatment
preference may be influenced by factors such as
the desire to return to work, litigation involvement,
workers compensation, and psychological issues.
All factors should be considered when determining
the most appropriate treatment choice for each
patient.
Lumbar discectomy has been performed for
over 70 years and open microdiscteomy is the most
common technique performed today. Minimally
invasive procedures attempt a smaller incision,
limited foraminotomy, and removal of displaced
disc tissue. The most common approach to the
lumbar spine for lumbar discectomy is a posterior
midline approach. The patient is placed in a prone
position on a radiolucent table (such as a Jackson
or Andrew’s table). Preoperative and intraoperative
radiographs or fluoroscopic images are taken to
guide the surgical approach to the correct level
of pathology. The most common complaint in
litigation cases against spine surgeons is wronglevel surgery, so identifying the correct level of
pathology before and during the surgical approach
is essential.
After the correct level is confirmed, a
standard laminotomy or partial laminectomy is
performed to adequately visualize the pathology.
Gentle retraction of neural elements will allow
visualization of the of disc material for removal.
An anulotomy or incision through the posterior
longitudinal ligament and anulus fibrosis can be
performed to access remaining herniated disc
tissue. A dose of 1 ml DepoMedrol® (80 mg) may
be applied to the affected nerve root for further
postoperative relief prior to closure.
Patients are often admitted postoperatively
for observation overnight, but surgery is also
performed in outpatient settings. Patients generally
experience improvement or resolution in leg pain
within 24 hours and often wake up from surgery
with dramatic relief. Any postoperative headache
should raise concern of a dural tear; patients
with these complaints should be kept supine until
symptoms improve.
Activity includes slow progressive walking
and activities of daily living as tolerated, starting
immediately. The patient should be educated on
postoperative restrictions, including no bending or
lifting over 10 lbs and no twisting. Physical therapy
for core strengthening may begin anywhere
between 2 and 6 weeks, with extension exercises
encouraged initially. Long car rides and heavy
lifting should be avoided for 3 months. Success
rates including pain relief from surgery are greater
than 90%. Recurrent herniation, as defined by
herniation after a pain-free period of 6 months, can
occur in 5 to 15% of patients.2
Authors have no relationship to disclose relating to the
content of this article
References
1.Lee JK, Amorosa L, Cho SL, Weidenbaum M, Kim Y. Recurrent lumbar disc herniation. J Am
Acad Orthop Surg. 2010; 18(6): 327-37.
2.Sharma H, Lee SW, Cole AA. The management of weakness caused by lumbar and
lumbosacral nerve root compression. J Bone Joint Surg Br. 2012; 94(11):1442-7.
3.Darden B, Kim D, Madigan L, Rhyne A, Spector LR: Cauda equina syndrome. J Am Acad
Orthop Surg. 2008; 16(8):471-9.
4.IA, Hyman GS, Packia –Raj LN, Cole AJ: The use of lumbar epidural/transforaminal steroids
for managing spine disease. J Am Acad Orthop Surg. 2007; 15(4): 228-38.
5.Butterman GR. Treatment of lumbar disc herniation: epidural steroid Injection compared with
discectomy. A prospective, randomized study. JBJS 2004; 86(4): 670-9.
6.Weinstein JN, et al: Surgical vs nonoperative treatment for lumbar disc herniation. The
Spine Patient Outcomes Research Trial (SPORT) A Randomized Trial: JAMA. 2006; 296(20):
2441-2450.
7.Weinstein JN, et al: Surgical versus nonoperative treatment for lumbar disc herniation: four
year results from the Spine Patient Outcome Research Trial (SPORT). Spine. 2008; 33(25):
2789-2800.
8.Radcliff K, et al. The impact of epidural steroid injections on the outcomes of patients treated
for lumbar disc herniation A subgroup analysis of the SPORT Trial. JBJS. 2012; 94(15): 1353-8.
9.Rihn JA, et al. Duration of symptoms resulting from lumbar disc herniation: Effect on
treatment outcomes analysis of the Spine Patient Outcomes Research Trial (SPORT). JBJS
2011; 93(20): 1906-14.
10.Peul WC, Arts MP, Brand R, Koes BW. Timing of surgery for sciatica: a subgroup analysis
alongside a randomized trial. Eur Spine J. 2009; 18(4): 538-45.
Image Quiz Answer
Answer: C. AP and lateral radiographs (Figures 1 and 2) show a left greater trochanteric fracture. Isolated
fractures of the greater trochanter usually result from direct impact. Controversy exists as to the best way to treat
isolated greater trochanteric fractures. It is difficult to establish a definitive diagnosis when plain films cannot rule
out a possible occult fracture extension. CT or MRI should be considered to rule out fracture extension; if negative,
immediate weight-bearing as tolerated can be initiated. Follow up radiographs should be obtained to monitor for
displacement secondary to the pull of the gluteus medius and gluteus minimus muscles.
FIGURE 3 CT image of the left hip. No fracture
extension is seen through the
trochanteric region.
FIGURE 4 CT image of the left hip showing the
isolated greater trochanteric fracture.
JOPA 21
Normal / Abnormal Image Review: Rotator Cuff Tears
Heather Killie, MD - New Hampshire Orthopaedic Center, Nashua, NH
NORMAL
FIGURE 1
ABNORMAL
FIGURE 2
Figure 1 is a normal coronal image of the right shoulder. Figure 2 (yellow arrow) shows an insertional tear at
the distal supraspinatus tendon. There is extension into the footprint, likely indicating a subtle full thickness
tear.
FIGURE 3
FIGURE 4
Figure 3 is a normal coronal image of the right shoulder. Figure 4 shows a large full thickness retracted
supraspinatus tear (yellow arrow), with fatty atrophy (blue arrow). There is evidence of supraspinatus
muscle volume loss.
22
JOPA
NORMAL
FIGURE 5
ABNORMAL
FIGURE 6
Figure 5 is a normal sagittal image of the left shoulder. Figure 6 shows a full thickness supraspinatus tear with
a yellow arrow indicating the absent tendon at the greater tuberosity footprint . The red arrow points to the
subscapularis tendon, the blue arrow to the infraspinatus tendon and the green arrow to the teres minor
tendon.
FIGURE 7
FIGURE 8
Figure 7 is a normal axial image of the right shoulder. Figure 8 shows a subscapularis tear with the yellow
arrow pointing to the free tendon edge. The subscapularis muscle belly appears attenuated (blue arrow).
There is slight subluxation of the biceps tendon (red arrow).
JOPA 23
Writing for JOPA: Information for Authors
The Journal of Orthopedics for Physician Assistants (JOPA) is a
peer-reviewed publication that delivers a broad range of orthopedic
content across all subspecialties. Authors can contribute any original
article that promotes an orthopedic education for physician assistants
(several examples are listed below). JOPA avoids publishing original
research and industry-sponsored articles, as well as articles previously
published or being considered for publication in other journals. Articles
are peer reviewed by a panel of orthopedic physicians and PAs to ensure
accuracy, clinical relevance, and readability.
References should be cited using the AMA Manual of Style, 10th edition. References should be recent and
predominately drawn from peer reviewed journals. Textbook and website references should be avoided if possible.
Article content, including the manuscript body and any tables, should be submitted in Microsoft Word format to
facilitate editing. Please use a standard font, such as Times New Roman, and a 12-point font size. Use appropriate
headings and subheadings in feature articles to organize paragraphs. JOPA reserves the right to edit content for space
and/or grammar issues. Any images that accompany an article must be sent as separate downloadable files from the
manuscript text for publishing.
Featured Review Articles
Featured review articles should contain a comprehensive
review of literature on an orthopedic topic of choice.
These academic literature reviews should be heavily
referenced and may be co-authored. Subspecialists
should consider writing on topics in their fields of
expertise. Featured review length should be 4-8 pages.
When considering the appropriate length, keep in mind
the clinical significance and readability of content.
Review Articles
Review articles should be 3-4 pages on an orthopedic
topic of choice. Review articles should be selective and
include few references. Authors may review a clinical
condition, surgical procedure, or any other topic related
to orthopedics. Preceptors may consider co-authoring a
review article with a PA student interested in pursuing a
career in orthopedics.
Case Studies
Case studies choose a case and provide a complete
history of the clinical presentation, treatment, and
outcome. Radiographs and other imaging should
be included to follow the course of a diagnosis and
treatment. Several learning points should be included at
the end of the case study, with appropriate references.
Please remove all patient identification information prior
to submission.
Case Reviews and Image Quizzes
Case reviews present a unique case with several images
and a brief description of the presentation, diagnosis,
and treatment. Image quizzes include an image for
24
JOPA
readers to interpret. Answers should be provided, with
a brief explanation of the patient and correct diagnosis.
Do not include literature review or references for case
reviews or image quizzes.
Be Creative!
Consider submitting a description of how your practice
uses PAs or the relationship you have with your
supervising physicians. Consider writing on a patient’s
experience and how it could be of value to PA colleagues.
Write a detailed narrative of a typical day in your life as
a PA. Personal experiences can be some of the most
interesting and helpful articles for other PAs to read. If
you have any other submission ideas, please contact the
editor at [email protected].
Supervising Physicians and
Allied Health Professionals
Supervising physicians may submit articles on topics in
their subspecialty or issues related to the PA profession.
Physicians may also choose to write on a procedure or
service unique to their practice. Co-authoring an article
with a supervising physician is a great way to promote
the physician-PA relationship. Nurse Practitioners
practicing in orthopedics are encouraged to contribute,
and may receive a free copy of JOPA by contacting
the editor or subscribing online. Contributions from
other allied health professionals, such as physical
therapists and athletic trainers, give PAs an opportunity
to learn from those with whom we share patient care
responsibilities. Allied health professionals who wish
to contribute to JOPA can contact the editor, Dagan
Cloutier, at [email protected].
Test Your Knowledge Quiz
Questions and Answers can be found at thejopa.org
1. A radial shaft fracture with associated
DRUJ dislocation is referred to as:
A
A. Mais
Maisonneauve
B. Galeazzi’s
C. Monteggia’s
D. Essex-Lopresti
2. A patient with right radicular arm pain
has a weak triceps reflex and decreased
sensation of the middle finger on exam.
Which cervical root is most likely being
impinged?
A. C5
B. C6
C. C7
D. C8
3. The classification for an 8-cm open
crush injury to the distal tibia with
fracture, moderate contamination,
and adequate soft tissue coverage
for closure is:
A. Type 2
B. Type 3a
C. Type 3b
D. Type 3c
4. Another name for calcaneal
apophysitis is:
A. Osgood-Schlatter disease
B. Sever’s disease
C. Ollier disease
D. Freiberg’s disease
5. Which type of suture is non-absorbable?
A. Monocryl
B. Vicryl
C. Polydioxanone (PDS)
D. Prolene
6. What Salta-Harris type is a fracture
through the epiphysis and physis,
but sparring the metaphysis?
A. 3
B. 2
C. 1
D. 5
7. Which is the best description of a
Garden Type 1 femoral neck fracture?
A. Varus impacted
B. Valgus impacted
C. Complete displacement
D. Stress reaction
8. Which shoulder test is indicative
of a SLAP lesion?
A. Yergason’s
B. Speed’s
C. O’Brien’s
D. Neer’s
9. What is the most common pediatric
bone tumor?
A. Osteochondroma
B. Osteoid osteoma
C. Giant cell tumor
D. Chondroma
10. A 46-year-old female runner has MRI
findings of a stress reaction with tension
sided edema to the left femoral neck
after several months of intense training.
What is the next best step in treatment?
A. Non-weight bearing for 6-8 weeks
B. Cannulated screw fixation
C. Weight-bearing as tolerated, but avoid
further running
D. Hemiarthroplasty
JOPA 25
Infectious Diseases Consult
Factors Influencing Antibiotic Choice for Acute Osteomyelitis
Kirthana Raman, PharmD
Tufts Medical Center, Boston, MA
Despite vast advancements in surgical and
pharmacologic treatments, osteomyelitis (OM)
remains a problematic infection. Several factors
contribute to OM’s chronicity and inability to
be eradicated. The largest barrier to treatment
is the lack of adequate vascularization within
bony tissue. Without sufficient vascularization,
pharmacologic therapies cannot reach the site of
infection at reasonable concentrations. Necrotic
OM also destroys the minimal vasculature that
exists, further diminishing antibiotic migration to
the site of infection. Furthermore, vascular disease
is often present in patients with OM, creating
another barrier to the achievement of therapeutic
antibiotic concentrations at the site of infection.
Although the ability to medically eradicate OM is
hotly debated, it is evident that a combination of
surgery and antibiotics is necessary for therapeutic
improvement, and we should optimize the use
of specific antibiotics (in terms of spectrum,
pharmacokinetics, and tolerability) to give patients
the best chance at improvement.
More than one-half of OM cases are caused
by Staphylococcal species, including methicillinresistant Staphylococcus aureus (MRSA), methicillinsusceptible Staphylococcus aureus (MSSA), and
coagulase-negative Staphylococcus species. Other
less common but clinically relevant organisms
include other gram positive organisms like
Streptococci or Enterococci, as well as gram negative
organisms like Pseudomonas, Enterobacter,
Proteus, Escherichia coli, and Serratia. For
necrotizing or rapidly progressing infections,
anaerobic organisms like Clostridium species and
Bacteroides fragilis should be considered.
Patients with diabetes, especially those
with diabetic foot infections, are likely to have
polymicrobial infections and are prone to infections
with Streptococcus. Polymicrobial infections
are also found in patients with decubitus ulcers,
penetrating trauma from a dirty source, and
necrosing OM.
If a patient has undergone multiple courses
26
JOPA
of broad-spectrum antibiotics, resistant gram
negative rods, including Pseudomonas, should
be considered. OM associated with surgical site
infections or hardware is most likely due to a
gram positive organism like Staphylococcus or
Streptococcus species, but gram negative organisms
may be involved in certain clinical situations. Bite
wounds, most commonly cat bites, can cause OM
associated with Prevotella species.
Using microbiological cultures will aid in
pathogen-directed therapy. Blood cultures will
commonly be positive for the causative pathogen
after radiographic diagnosis of OM. Bone cultures
obtained operatively will usually be positive for
OM, as long as antibiotics were withheld prior to
surgery.1 If cultures are negative, therapy should
include antibiotics aimed at the most likely
pathogens, including Staphylococcus species.
Antibiotic choice should always incorporate
concepts like spectrum of activity (coverage
of the fewest possible organisms to prevent
superinfections or resistance), patient tolerability
(OM treatment requires weeks to months of
therapy), and bone penetration.
Vancomycin (Vancocin) is the most common
antibiotic used for OM treatment. Vancomycin is
an inexpensive intravenous (IV) antibiotic that
is bactericidal against gram positive species,
including all Staphylococcal species. It does not
have activity against any gram negative organisms.
Due to its spectrum of activity, vancomycin can
be used for culture-proven gram MRSA infections.
In combination with fluoroquinolone or a betalactam, vancomycin provides broad gram positive
and gram negative activities for polymicrobial
infections.
Vancomycin is accompanied by a myriad
of adverse effects, most notably nephrotoxicity.
The risk of vancomycin nephrotoxicity is thought
to be highest with high doses of vancomycin (>4
grams per day), prolonged courses (> 14 days),
concomitant nephrotoxins, and baseline kidney
disease. Although vancomycin is commonly used
for OM, its penetration into bone is suboptimal.
Bone concentrations of vancomycin have been
measured between 5–40% of serum levels, with
variations by time after dose, type of bone, and
variations in sampling/assaying.1 Although the
measured bone levels were relatively low, there
have been numerous documented successes with
the use of vancomycin for OM.
Clindamycin (Cleocin) is an antibiotic that
has been used to treat OM for over 40 years.
Clindamycin is available in oral and IV formulations,
and is effective against gram positive and anaerobic
organisms. Like vancomycin, clindamycin does not
have activity against gram negative organisms. It is
generally well tolerated by patients but can cause
diarrhea or rash. Additionally, due to its availability
as both an oral and IV medication, patients can be
easily transitioned off IV antibiotics. Clindamycin
is considered to have good bone penetration,
with concentrations ranging between 21 and 45%
of serum levels.1 Higher concentrations have
been achieved in infected bone compared to
healthy bone. Although a more traditional agent,
clindamycin remains a mainstay in OM therapy,
either alone or in combination with a gram negative
agent like a fluoroquinolone or tetracycline.
Fluoroquinolones including levofloxacin
(Levaquin), ciprofloxacin (Cipro), and moxifloxacin
(Avelox) have gained favor over the past few
decades in OM therapy. All of the fluoroquinolones
have broad gram positive and gram negative
activities. None of the fluoroquinolones have
activity against MRSA or coagulase-negative
S. aureus. Levofloxacin and ciprofloxacin have
activity against some multi-drug resistant gram
negative organisms, and moxifloxacin has activity
against anaerobic organisms.
Table 1. Empiric Therapy Options
Risk Factor
Likely Organism
Empiric Treatment Options
Hematogenous
Staphylococcus aureus
Oxacillin 2g IV q 4-6 h
Vancomycin 15-20 mg/kg IV q 8-12 h
Daptomycin 6 mg/kg IV once daily
Linezolid 600 mg orally or IV twice daily
Clindamycin 600 mg orally or IV q 8 h
Diabetes, Vascular Insufficiency
Group B Streptococcus
Ampicillin 2g IV q4-6 h
Polymicrobial
Vancomycin 15-20 mg/kg IV q 8-12 h±
Ciprofloxacin 400 mg IV q 12 h or 500 mg PO
q 12 h
Open fractures
S. aureus
Pseudomonas aeruginosa
E. coli
Ciprofloxacin 400 mg IV q12h or 500 mg PO q
12 h ± Vancomycin 15-20 mg/kg IV q 8-12 h
Hardware Infection
S. aureus,
Coagulase negative Staph
Vancomycin 15-20 mg/kg IV q 8-12 h
IV Drug Use
S. aureus
Streptococcus spp.
Oral Anaerobes (if licks needles)
Ampicillin/ sulbactam 3g IV q 6 h
Foot puncture with soaking / moisture
Pseudomonas
Piperacillin/ tazobactam 3.375g q 6 h (or q 8 h
if administered over 4 h infusion)
Human bite
Oral anerobes, Eikinella spp., Viridans group
Streptococcus
Ampicillin/ sulbactam 3g IV q 6 h
Cefoxitin 1g IV q 6-8 h
Ertapenem 1g IV q 24 h
Animal bite
Pasturella multocida
Bartonella henselae
Ampicillin/ sulbactam 3g IV q 6 h
Ertapenem 1g IV q 24 h
Doxycycline 100 mg IV or PO q 12 h
Sickle cell
S. aureus
Salmonella spp.
Ciprofloxacin 400 mg IV q 12 h or 500 mg PO
q 12 h
* Suggested Treatment of Acute Osteomyelitis is 4-6 weeks duration. Transition from IV to oral antibiotics is based on
clinical stability. De-escalation to a narrow-spectrum antibiotic should be performed on receipt of culture results.
JOPA 27
Long-term or frequent use of fluoroquinolones,
although well tolerated, has been linked to an
increase in gram negative resistance. All of these
agents can cause nausea and diarrhea, and have all
been rarely linked with tendon rupture and sudden
cardiac death. In patients without cardiac disease,
fluoroquinolones are well tolerated and only require
dosing once or twice per day. Fluoroquinolones are
all available in IV and oral formulations, facilitating
IV transition, and are all relatively inexpensive. All
of these agents have very high bone penetration,
reaching bone concentrations between 40 and 120%
of serum levels. When measured separately, there
are higher levels in cancellous bone than in cortical
bone.1 Fluoroquinolones remain a reliable option for
pathogen-directed or empiric broad-spectrum OM
treatment.
These agents are generally inexpensive,
relatively well tolerated, and can be used over a
long period of time without serious consequences.
Approximately 10% of the population reports
allergies to beta-lactam antibiotics; however, only
1% of the population has a true allergy. The fraction
of bone penetration is relatively low, at 10 to 30%
of serum levels; however, serum concentrations of
beta-lactams are often much higher than needed and
low penetration of such high concentrations may be
sufficient for effective therapy.1 Therefore, penicillins
and cephalosporins are often a first-line option for
broad empiric and pathogen-directed therapy of OM.
Treatment of OM is complex and requires
thoughtful interventions. When treating a patient
with OM, a combination of antibiotics and surgical
intervention is necessary for effective therapy.
However, these patients are rarely critically or acutely
ill, and orthopedists are urged to postpone antibiotic
initiation until after surgical intervention and after
cultures are obtained to optimize microbiologic
findings. When initiating therapy, clinicians should take
care to incorporate multiple factors, like tolerability,
spectrum of activity, and bone penetration.
Penicillins and cephalosporins (beta-lactam
antibiotics) are some of the oldest antibiotics
available and have been used extensively in the
treatment of OM. These agents vary greatly in their
spectrum of activity, from penicillin (narrowest) to
cefepime (broadest), with some available for oral
administration and some IV. Most beta-lactams have
activity against MSSA and Streptococcal species. Only
the newest cephalosporin, ceftaroline (Teflaro), has
activity against MRSA and coagulase-negative S.
aureus.
The author has no relationship to disclose relating to the
content of this article
Reference
1.Landersdorfer CB, Bulitta JB, Kinzig M, Hozgrabe U, Sorgel F. Penetration of
Antibacterials into bone: Pharmacokinetic, Pharmacodynamic, and
Bioanalytical Considerations. Clin Pharmacokinet. 2009; 48(2): 89-124.
Join the JOPA Editorial Board
All articles submitted to JOPA are reviewed
by the Editor in Chief, who is responsible for
deciding whether an article is accepted, rejected,
or in need of revision before publication. JOPA
will be forming an editorial board by subspecialty.
Each subspecialty section will be represented
by a physician assistant or section editor whose
knowledge and experience lies within the chosen
subspecialty. Each section editor will review
submitted articles within their subspecialty prior
to publication and send articles to a group of peer
reviewers who share knowledge and experience in
the subspecialty. Once peer reviewed, authors will
have the opportunity to revise their article and
re-submit for publication. This will ensure that all
articles published in JOPA are accurate, clinically
relevant, and readable. Anyone interested in joining
the editorial board should email, Dagan Cloutier,
Editor in Chief, at [email protected].
28
JOPA
Subspeciality
Sections
•
•
•
•
•
•
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Hand
Spine
Trauma
Arthroplasty
Sports
Foot and Ankle
Pediatrics
Tumor
Preoperative Decolonization of MSSA/MRSA
Nasal Carriage and the Effect on Orthopedic
Postoperative Surgical Site Infections
Joshua Radi, PA-C
Loyola University Medical Center, Maywood, IL
Postoperative surgical site infections (SSIs) are a
major factor in the morbidity and mortality in patients
undergoing elective or non-elective orthopedic
surgery. The most common pathogenic organism in
such cases is Staphylococcus aureus.1,2 Although this
gram-positive bacterium is a part of the natural flora
in most individuals, it can become pathogenic in
some hosts. As over-prescribing and under treatment
with antibiotics has increased, the level of antibiotic
resistance in microorganisms such as S. aureus has
also increased.
S. aureus primarily colonizes the nares, axillae,
and groin, but can occur at any topical site on the
body. The carrier rate of S. aureus in the nares of the
general population ranges from 20-30%,16,26-31 with 3% of
these cases due to methicillin-resistant Staphylococcus
aureus (MRSA).2-3 The Veterans Affairs population has
MRSA nasal colonization rates approaching 7%.13 The
S. aureus isolated from the nares and postoperative
surgical wounds tends to be identical.19 A direct
epidemiological link is present between S. aureus in the
nares and the development of S. aureus SSI.16-19 Of these
S. aureus SSIs, patients with preoperative positive
nasal MRSA colonization have an increased risk of
postoperative MRSA infection compared to those
without colonization.3,20-25
One major risk factor for MRSA colonization is a
recent hospital admission.14-15 One study evaluating the
prevalence of MRSA carriage in trauma and orthopedic
patients showed that 4% of patients are negative for
MRSA on admission, but are positive on discharge.3
Another study of 20,000 mixed surgical patients showed
that 57% of infected patients are not colonized with
MRSA during admission but acquire MRSA infections
during their hospitalization.4
the surgical field. Seeding through the bloodstream is
another potential route for SSI.6-7
SSIs can have devastating consequences.
For example, based on United States data from the
National Inpatient Sample database, 25% of total
knee revisions are performed because of infection.8
Treatment may require a two-stage revision surgery:
removal of hardware, placement of antibiotic spacers,
and 6-8 weeks of intravenous (IV) antibiotics, followed
by removal of the antibiotic spacer and revision
surgery after the initial infection is eradicated. Some
studies show that the cost of revision surgery in total
joint arthroplasty (TJA) due to infection approaches
four times the cost of a primary TJA.9-11 Up to 25% of
such SSIs may not be clinically evident until 2 years
after the initial operation.12
Improvements in patient surgical site
preparation, sterility precautions in the operating
room, and use of perioperative antibiotics have
reduced elective orthopedic SSIs to an average of
below 2%.12-13 Additionally, many institutions have
protocols that place patients who screen positive
for MRSA in isolation with contact precautions.
Such protocols have significantly decreased the
rate of infection and may be one of the most
important measures in preventing infection.56-57
These
precautions
reduce
patient-to-patient
transmission in the hospital by health care workers
and underscore the importance of proper hand
washing or use of alcohol-based rubs. Although
the rates of postoperative SSI have decreased, the
goal is to reduce this infection rate further. Nasal S.
aureus carriage is thought to be an important risk
factor for SSI, suggesting that preoperative nasal
decolonization could play a role in reducing these
infections.32
DECOLONIZATION
MRSA IN ORTHOPEDIC SSI
The prevalence of MRSA in deep orthopedic SSIs is
increasing.1,5 Two different types of MRSA transmission
are known. Endogenous MRSA comes from the patient’s
own flora (including the nares), and exogenous MRSA
comes from iatrogenic sources. Transmission may be
possible from aerosolized bacteria from the nose of
the patient released during surgery that contaminates
Many institutions have implemented the
use of preoperative nasal methicillin-sensitive
Staphylococcus aureus (MSSA)/MRSA screens for
elective surgical procedures. These screens are
performed using nasal swabs followed by laboratory
testing to identify the organism. Positive nasal MRSA
screens have resulted in perioperative decolonization
protocols in an effort to reduce SSIs. However, nasal
JOPA 29
MRSA screens have false-negative results in 5-10% of
cases.33-35 A recent study demonstrated that a history
of a negative MRSA culture cannot be reliably used in
place of a preoperative nasal MRSA screen to identify
MRSA carriers because it misses over 80% of patients
who tested positive for MRSA with preoperative nasal
polymerase chain reaction.13
Patients who test positive for MSSA/MRSA are
often decolonized preoperatively. Multiple techniques
are available for the decolonization of nasal MSSA/
MRSA. These include oral antibiotics such as rifampin
and doxycycline, intranasal topical agents such as
mupirocin (2%) and povodone-iodine (5%), and skincleansing topical agents such as chlorhexidine (2%).58
Oral antibiotics have the most side effects, longest
treatment protocol, highest resistance patterns, and
worst penetration in the nares, making topical agents
the first-line choice.
Mupirocin is a natural antibiotic from
Pseudomonas fluorescens and is effective in
eradicating MSSA and MRSA from the nares.17-18,36
This method reaches decolonization rates of 83%
with short-term nasal protocols.18 Mupirocin is a safe
and well-tolerated method for nasal decolonization,
with superficial irritation being the largest adverse
reaction.22,36 Mupirocin is also believed to be safe in
combination with chlorhexidine baths, which can
eradicate MRSA and other bacteria from the skin.37
Povodone-iodine agents have also been used primarily
with mupirocin-resistant strains.58 Decolonization of
nasal MRSA with mupirocin and chlorhexidine baths
results in a statistically significant decrease in MRSA
and total S. aureus isolates in the clinical laboratory.38
“Treatment” of MRSA skin and wound infections
is different than “decolonization” of asymptomatic
nasal MSSA/MRSA carriers, and these terms should
not be used interchangeably. The decolonization of
MRSA in the nares varies by institution, making largescale meta-analyses difficult. Currently, nationwide
guidelines do not routinely recommend protocols/
procedures for MRSA screening.39 No real agreement
exists among institutions regarding the duration,
frequency, and/or addition of chlorhexidine baths for
the decolonization of MSSA or MRSA in the nares of
carriers.
The most common perioperative eradication
method for positive nasal MRSA screens is mupirocin
2% topical ointment placed intranasally twice a day for
5 days plus chlorhexidine baths once every other day
for the 5 days prior to surgical intervention. Patients
undergoing elective surgical procedures may have
follow-up appointments before surgery to confirm
decolonization. This is routinely done in combination
30
JOPA
with perioperative IV cefazolin for MRSA-negative
MSSA carriers and IV vancomycin for MRSA carriers.
For hospital decolonization of positive nasal MRSA
carriers with nasal application of mupirocin and
chlorhexidine, body soaks for 5 days significantly
decrease MRSA bacteremia and iatrogenic MRSA
disease but have no impact on MSSA bacteremia.1,16
The above decolonization protocol with mupirocin
and chlorhexidine results in a rate of MRSA SSI that
decreases from 0.23% to 0.09% in all surgical patients
and from 0.30% to 0% in TJA procedure patients.55
No current set of approved guidelines is
available regarding empiric decolonization of
nasal MSSA/MRSA versus screening followed by
decolonization for preoperative elective orthopedic
surgical cases.50 The latter approach for MRSA nasal
carriage may prevent mupirocin resistance but does
not appear to be cost-effective.
Resistance is a common concern in using
antibiotics. Concerns for mupirocin or chlorhexidine
resistance with frequent use of these agents has
raised questions about the empiric decolonization
method.42-44 However, short courses used specifically
for decolonization prior to operative intervention
are not expected to cause widespread resistance.45
Mupirocin blocks protein synthesis in bacteria, and
because this mechanism of action is distinct from
other antibiotics, the opportunity for resistance is
reduced.
The decolonization of all patients, regardless
of risk factors or likelihood of resistance, should
be approached with caution. Risk factors include
hospitalization within the past 24 months, current
prolonged hospitalization, outpatient visit within the
past 12 months, nursing home admission within the
past 12 months, antibiotic exposure within the past
12 months, age over 65 years, co-morbid conditions,
IV drug use, history of invasive procedures, and/
or close contact with a person who has any of the
above risk factors.58 A study from the UK in 2009
recommended discontinuation of MRSA screening
of all outpatient surgical patients due to poor use
of resources, although the authors did note some
utility in patients older than 65 years and with
significant co-morbidities.51 Some studies show
significant yearly economic gain with preoperative
decolonization using mupirocin and chlorhexidine,
reporting savings that approach $275,000 per year
due to reduced SSIs.2,26
Is there a correlation between preoperative
decolonization of MRSA in the nares and a reduction
in postoperative MRSA SSIs? Many non-orthopedic
surgical subspecialties have examined these data,
with varying results. Treatment with preoperative
intranasal mupirocin and oral bactrim resulted in
zero postoperative MRSA wound infections after
dermatology outpatient surgery as compared to
0.3% without treatment.46 Preoperative treatment of
cardiac surgery patients with mupirocin revealed no
beneficial effects.47 A well-done systematic review
and meta-analysis published in 2009 compared
hospital wards applying rapid MRSA screening tests
with proper decolonization to those that did not,
and noted a significantly decreased risk for MRSA
bloodstream infections but not for MRSA SSI.52
Decolonization studies in 2008/2009 in
orthopedic surgery yielded mixed results. No
reduction in orthopedic S. aureus SSIs was noted
in two studies when using mupirocin, but articles
published in the same years showed a reduction in
orthopedic S. aureus SSIs.29,31,48-49 In 2010, orthopedic
surgery patients were screened preoperatively for
MRSA, and the authors concluded that hospitals
and third-party payers would save money in most
circumstances compared to not screening.53 Glassner
et al. were unable to obtain definitive conclusions
regarding MRSA screening for TJA patients in 2011,
but stated that due to the significant cost and
morbidity associated with postoperative MRSA
infection, protocols for screening and decolonization
should be considered for all elective or emergent
surgical patients.54 The most recent data in 2011
showed that orthopedic surgical patients treated
preoperatively with a combination of mupirocin and
chlorhexidine had a decrease in TJA SSIs from 2.7% to
1.4%.26 This was replicated in a 2-year follow-up study
that showed a decrease from 2.7% to 1.2%.2
CONCLUSION
Currently, high-quality data on preoperative
decolonization with mupirocin alone and/or in
combination with chlorhexidine in non-elective
orthopedic trauma patients are lacking. Due to the
necessity of urgent fixation and/or stabilization of
most orthopedic trauma patients, decolonization is
not possible, making this type of research difficult.
However, the most recent evidence does support
the use of preoperative nasal MRSA decolonization
in elective TJA.2 From an economic standpoint, the
development of techniques to prevent postoperative
SSIs is imperative, since hundreds of thousands
of dollars could be saved by preventing revision
surgeries.2,26 The majority of publications suggest
some benefit of nasal MRSA decolonization prior to
elective orthopedic surgery, although a need clearly
exists for a large, multi-center study to clarify the
best treatment for preoperative orthopedic surgical
patients who are nasal MSSA/MRSA carriers. This
type of research will allow stratification of beneficial
long-term data into models that may be used as the
epicenter for new and improved national guidelines.
The author has no relationship to disclose relating to the
content of this article
REFERENCES
1. Anderson DJ, Sexton DJ, Kanafani ZA, et al. Severe surgical site infection
in community hospitals: epidemiology, key procedures, and the changing
prevalence of methicillin-resistant Staphylococcus aureus. Infect Control Hosp
Epidemiol. 2007; 28(9):1047-53.
2. Rao N, Cannella BA, Crossett LS, et al. Preoperative screening/
decolonization for Staphylococcus aureus to prevent orthopaedic surgical site
infection: prospective cohort study with 2-year follow-up. J Arthoplasty. 2011;
26(8):1501-1507.
3. Walley G, Orendi J, Bridgman S, Davis B, Ahmed E, Maffulli N. Methicillin
resistant Staphylococcus aureus (MRSA) is not always caught on the
orthopaedic ward. Acta Orthop Belg. 2009; 75(2):245-251.
4. Harbath S, Fankhauser C, Schrenzel J, et al. Universal screening for
methicillin-resistant Staphylococcus aureus at hospital admission and
nosocomial infection in surgical patients. JAMA. 2008;299(10):1149-57.
5. Spellberg B, Guidos R, Gilbert D, Bradley J, Boucher HW, Scheld WM,
Bartlett JG, Edwards Jr. J. The epidemic of antibiotic resistant infections: a call
to action for the medical community from the Infectious Diseases Society of
America. Clin Infect Dis. 2008; 46(2):155-164.
6. Casewell MW: The nose: an underestimated source of Staphylococcus aureus
causing wound infection. J Hosp Infect. 1998;40(suppl B):3-11.
7. Kluytmans JA: Reduction in surgical site infections in major surgery
by elimination of nasal carriage of Staphylococcus aureus. J Hosp Infect.
1998;40:S25-29.
8. Bozik KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total knee
arthroplasty in the United States. Clin Orthop Relat Res. 2010;468(1):45-51.
9. Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty
on hospital and surgeon resource utilization. J Bone Joint Surg Am.
2005;87(8):1746-51.
10. Hebert CK, Williams RE, Levy RS, Barrack RL. Cost of treating an infected
total knee replacement. Clin Orthop Relat Res. 1996; 331: 140-145.
11. Lavernia C, Lee DJ, Hernandez VH. The increasing financial burden
of knee revision surgery in the United States. Clin Orthop Relat Res. 2006;
446:221-226.
12. Kurtz SM, Ong KL, Lau E, et al. Prosthetic joint infection risk after TKA in
the Medicare population. Clin Orthop Relat Res. 2010;468:52.
13. Strymish J, Branch-Elliman W, Itani KMF, Williams S, Gupta K. A clinical
history of methicillin-resistant Staphylococcus aureus is a poor predictor of
preoperative colonization status and postoperative infections. Infect Control
Hosp Epidemiol. 2012;33(11):1113-1117.
14. Scudeller L, Leoncini O, Boni S et al. MRSA carriage: the relationship
between community and healthcare setting: A study in an Italian hospital. J
Hosp Infect. 2000;46(3):222-29.
15. Warshawsky B, Hussain Z, Gregson DB et al. Hospital and communitybased surveillance of methicillin-resistant Staphylococcus aureus: previous
hospitalization is the major risk factor. Infect Control Hosp Epidemiol.
2000;21(11):724-727.
16. Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus
aureus: epidemiology, underlying mechanisms, and associated risks. Clin
Microbiol Rev. 1997;10(3):505-520.
17. Perl TM, Golub JE. New approaches to reduce Staphylococcus aureus
Nosocomial infection rates: treating S. aureus nasal carriage. Annals
Pharmacother. 1998;32:S7.
18. Wenzel RP, Perl TM. The significance of nasal carriage of Staphylococcus
aureus and the incidence of postoperative wound infection. J Hospital Infec.
1995;31:13.
19. Perl TM, Cullen JJ, Wenzel RP, et al. Intranasal mupirocin to prevent
postoperative Staphylococcus aureus infections. New Engl J Med.
2002;346(24):1871-1877.
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20. Diekema D, Johannsson B, Herwaldt L, et al. Current practice in
Staphylococcus aureus screening and decolonization. Infect Control Hosp
Epidemiol. 2011;32(10):1042-1044.
40. Cimochowski GE, Harostock MD, Brown R, et al. Intranasal mupirocin
reduces sternal wound infection after open heart surgery in diabetics and
nondiabetics. Ann Thorac Surg. 2001;71(5):1572-1578.
21. Kluytmans JAJW, Mouton JW, Ijzerman EP, et al. Nasal carriage of
Staphylococcus aureus as a major risk factor for wound infections after cardiac
surgery. J Infect Dis. 1995;171(1):216-219.
41. Wertheim HF, Vos MC, Ott A, Voss J, Kluytmans A, VandenbrouckeGrauls CM, Meester MH, van Keulen PH, Verbrugh HA. Mupirocin
prophylaxis against nosocomial Staphylococcus aureus infections in
nonsurgical patients: a randomized study. Ann Intern Med. 2004;140(6):419425.
22. Bode LG, Kluytmans JA, Wertheim HF, et al. Preventing surgical site
infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010;
362(1):9-17.
23. Gupta K, Strymish J, Abi-Haidar Y, Williams SA, Itani KM. Preoperative
nasal methicillin-resistant Staphylococcus aureus status, surgical prophylaxis,
and risk-adjusted postoperative outcomes in veterans. Infect Control Hosp
Epidemiol. 2011;32(8):791-796.
24. Datta R, Huang SS. Risk of infection and death due to methicillin-resistant
Staphylococcus aureus in long-term carriers. Clin Infect Dis. 2008;47(2):176181.
25. Huang SS, Platt R. Risk of methicillin-resistant Staphylococcus aureus
infection after previous infection or colonization. Clin Infect Dis. 2003;36:281285.
26. Rao N, Cannella B, Crossett LS, et al. A preoperative decolonization
protocol for Staphylococcus aureus prevents orthopaedic infections. Clin
Orthop Relat Res. 2008; 466(6):1343-8.
27. Perl TM. Prevention of Staphylococcus aureus infections among surgical
patients: beyond traditional perioperative prophylaxis. Surgery. 2003;134 (5
Suppl):S10.
28. Kim DH, Spencer M, Davidson SM, et al. Institutional prescreening for
detection and eradication of methicillin-resistant Staphylococcus aureus
in patients undergoing elective orthopaedic surgery. J Bone Joint Surg.
2010;92(9):1820-6.
29. Hacek DM, Robb WJ, Paule SM, et al. Staphylococcus aureus nasal
decolonization in joint replacement surgery reduces infection. Clin Orthop
Relat Res. 2008;466(8):1349-1355.
30. Price CS, Williams A, Philips G, Dayton M, Smith W, Morgan S.
Staphylococcus aureus nasal colonization in preoperative orthopaedic
outpatients. Clin Orthop Relat Res. 2008; 466(11):2842-2847.
31. Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, et al. Surgical
site infections in orthopaedic surgery: the effect of mupirocin nasal ointment
in a double-blind, randomized, placebo-controlled study. Clin Infect Dis.
2002;35(4):353-8.
32. Kalmeijer MD, van Niewwland-Bollen E, Bogaers-Hofman D, et al.
Nasal carriage of Staphylococcus aureus is a major risk factor for surgicalsite infections in orthopaedic surgery. Infect Control Hosp Epidemiol.
2000;21(5):319-23.
33. Wolk DM, Picton E, Johnson D, et al. Multicenter evaluation of the
Cepheid Xpert methicillin-resistant Staphylococcus aureus (MRSA) test as
a rapid screening method for detection of MRSA in nares. J Clin Microbiol.
2009;47(3):758-764.
34. De San N, Denis O, Gasasira MF, De Mendonca R, Nonhoff C, Struelens
MJ. Controlled evaluation of the IDI-MRSA assay for detection of colonization
by methicillin-resistant Staphylococcus aureus in diverse mucocutaneous
specimens. J Clin Microbiol. 2007;45(4):1098-1101.
35. Olchanski N, Mathews C, Fusfeld L, Jarvis W. Assessment of the influence
of test characteristics on the clinical and cost impacts of methicillin-resistant
Staphylococcus aureus screening programs in US hospitals. Infect Control Hosp
Epidemiol. 2011;32(3):250-257.
42. Leski TA, Gniadkowski M, Skoczynska A, et al. Outbreak of mupirocinresistant staphylococci in a hospital in Warsaw, Poland, due to plasmid
transmission and clonal spread of several strains. J Clin Microbiol.
1999;37(9):2781-8.
43. Deshpande LM, Fix AM, Pfaller MA, et al. Emerging elevated mupirocin
resistance rates among staphylococcal isolates in the SENTRY Antimicrobial
Surveillance Program (2000): correlations of results from disk diffusion, Etest
and reference dilution methods. Diagn Microbiol Infect Dis. 2002;42(4):283-90.
44. Batra R, Cooper BS, Whiteley C, et al. Efficacy and limitation of a
chlorhexidine-based decolonization strategy in preventing transmission of
methicillin-resistant Staphylococcus aureus in an intensive care unit. Clin
Infect Dis. 2010;50(2):210-7.
45. Ammerlaan HS, Kluytmans JA, Wertheim HF, et al. Eradication of
methicillin-resistant Staphylococcus aureus carriage: a systematic review. Clin
Infect Dis. 2009; 48(7):922-30.
46. Cordova KB, Grenier N, Chang KH, Dufresne R Jr. Preoperative
methicillan-resistant Staphylococcus aureus screening in Mohs surgery
appears to decrease postoperative infections. Dermatol Surg. 2010;36(10):15371540.
47. Konvalinka A, Errett L, Fong IW. Impact of treating Staphylococcus
aureus nasal carriers on wound infections in cardiac surgery. J Hosp Infect.
2006;64(2):162-168.
48. Gernaat-van der Sluis AJ, Hoogenboomm-Verdegaal AM, Edixhoven PJ, et
al. Prophylactic mupirocin could reduce orthopedic wound infections. 1,044
patients treated with mupirocin compared with 1,260 historical controls. Acta
Orthopaedica Scand. 1998;69(4):412-4.
49. Nixon M, Jackson B, Varghese P, et al. Methicillin resistant Staphylococcus
aureus on orthopaedic wards: incidence, spread, mortality, cost and control. J
Bone Joint Surg Br. 2006;88(6):812-7.
50. Courville XF, Tomek IM, Kirkland KB, Birhle M, Kantor SR, Finlayson
SRG. Cost-effectiveness of preoperative nasal mupirocin treatment in
preventing surgical site infection in patients undergoing total hip and knee
arthroplasty: a cost-effectivenss analysis. Infect Control Hosp Epidemiol.
2012;33(2):152-159.
51. Enoch DA, Carter NM, Karas JA. MRSA screening of elective surgery daycase patients. J Hosp Infect. 2010;74(3):291-292.
52. Tacconelli E, De Angelis G, de Waure C, Cataldo MA, La Torre G, Cauda
R. Rapid screening tests for methicillin-resistant Staphylococcus aureus at
hospital admission: systematic review and meta-analysis. Lancet Infect Dis.
2009;9(9):546-554.
53. Lee BY, Wiringa AE, Bailey RR, Goyal V, Tsui B, Lewis GJ, Muder RR,
Harrison LM. The economic effect of screening orthopedic surgery patients
preoperatively for methicillin-resistant Staphylococcus aureus. Infect Control
Hosp Epidemiol. 2010;31(11): 1130-1138.
54. Glassner PJ, Slover JD, Bosco JA, Zuckerman JD. Blood, bugs, and motion:
What do we really know in regard to total joint arthroplasty? Bull NYU Hosp Jt
Dis. 2011;69(1):73-80.
36. Ammerlaan HS, Kluytmans JA, Wertheim HF, et al. Eradication of
methicillin-resistant Staphylococcus aureus carriage: a systematic review. Clin
Infect Dis. 2009;48(7):922-30.
55. Pofahl WE, Goettler CE, Ramsey KM, Cochran MK, Nobles DL, Rotondo
MF. Active surveillance of MRSA and eradication of the carrier state decreases
surgical-site infections caused by MRSA. J Am Coll Surg. 2009;208(5):981-986.
37. Kaiser AB, Kernodle DS, Barg NL, et al. Influence of preoperative showers
on staphylococcal skin colonization: a comparative trial of antiseptic skin
cleansers. Annals Thoracic Surg. 1988;45(1):35-8.
56. Chalfi ne A, Kitzis MD, Bezie Y, Benali A, Perniceni L, Nguyen JC, Dumay
MF,Gonot J, Rejasse G, Goldstein F, Carlet J, Misset B: Ten-year decrease of
acquired methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
at a single institution: the result of a multifaceted program combining cross
transmission prevention and antimicrobial stewardship. Antimicrob Resist
Infect Control. 2012;1(18):1-7.
38. Hacek DM, Paule SM, Thomson RB Jr, Robicsek A, Peterson LR.
Implementation of a universal admission surveillance and decolonization
program for methicillin- resistant Staphylococcus aureus (MRSA) reduces
the number of MRSA and total number of S. aureus isolates reported by the
clinical laboratory. J Clin Microbiol. 2009;47(11):3749-3752.
39. Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site
infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(suppl
1):S51-S61.
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57. Landelle C, Pagani L, Harbarth S. Is patient isolation the single most
important measure to prevent the spread of multidrug-resistant pathogens?
Virulence. 2013;4(2):0-1.
58. Larkin SA, Murphy BS. Preoperative decolonization of methicillin-resistant
Staphylococcus aureus. Orthopedics. 2008;31(1):37-41.
PA Owned and Operated
Brant Bell, PA-C
Seven Springs Orthopaedics & Sports Medicine, Brentwood, TN
The fall season brings about several events
that can be summed up in one simple word:
change. As the warmth of summer begins to ebb
and the coolness of fall begins to dominate the air,
change is inevitable. The flowers wither; the pace
of the growing grass slows and it fades to brown;
and best of all, the leaves begin to morph into a
sea of vibrant colors that amaze and bewilder at
the same time. It would be difficult to name a more
beautiful season of change than the fall, especially
in Middle Tennessee, where I live and work.
Change. This word causes a wave of emotions
in all of us. We have all experienced change.
Benjamin Franklin said, “The only things certain in
life are death and taxes.” One could argue the quote
should read, “The only things certain in life are
death, taxes, and change.” Change can cause you to
cringe in fear about what is happening around you,
or can breathe life into a stale environment. In my
career as a physician assistant, I have witnessed
both ends of the spectrum and experienced highs
and lows.
In the fall of 2005, I was practicing orthopedics
in a small practice with two surgeons and two PAs,
including myself. My PA partner and I would treat
approximately 80 of the 100 patients that came
through the clinic doors each day. It was, and still is,
a wonderful place to practice orthopedic medicine.
The setting was pristine: a brand new office space
located in the most coveted part of town. The two
surgeons treated me well and taught me a great
deal about orthopedics; our relationship grew and
developed trust and respect that any PA would
covet. I was not interested in change. I was content
– or so I thought. As the grind of each day wore
on, I became somewhat bitter about the situation.
Bitterness was admittedly not the healthiest way
to respond to my situation, but I’m trying to be
truthful about the feelings I experienced and how
I chose to deal with them. Rather than bury the
bitterness and allow it to fester, I decided to do
something about it.
I was fully aware of the revenue I was
generating for the clinic by personally treating
Brant Bell, PA-C
Stu Jones, PA-C
approximately 40 patients per day. My PA partner
and I approached the surgeons to ask for a
productivity bonus based on the revenue we
generated for the clinic. The request was not well
received. We were told that we had “topped out”
in terms of earning potential, and “if you can find
something better to do, go do it.” Those words
reverberated in our minds for weeks as we decided
how to respond. We experienced a variety of
emotions as we processed the surgeons’ response.
JOPA 33
As my PA partner and I talked about it each day,
we came to the conclusion that something had to
change. There’s that word again: change.
How do you change a situation if you do
not know what the options are for change? As we
pondered our possible moves, we contacted the
attorney who represents the Tennessee Academy
of Physician Assistants (TAPA) to explore options.
What we found breathed life into dreams we had
been discussing. We found that Tennessee is a very
favorable state for PA-owned practices. Several
discussions by phone and email with the TAPA
attorney ensued, and it was increasingly clear
that our dreams could become reality. We leaped
into establishing Seven Springs Orthopaedics
and Sports Medicine, knowing that a PA-owned
specialty clinic had never existed. Being the first
at something is very exciting, but also brings many
challenges.
Funding such a venture is one of the largest
obstacles to overcome. We created a business plan
and met with three executives at a local bank to
make our presentation. The bank agreed to become
our lender for the project. One of the fastest ways
to fail in business is to be underfunded, so we
secured a revolving line of credit that would allow
us to continue to fund the venture, knowing that
it takes time to grow a medical clinic to a selfsustaining revenue generator.
Our next big hurdle was deciding where to
place the clinic. Our non-compete clause meant we
could not be in the same county as our previous
employer. We found a new medical office building
in the next county, signed a 10-year lease, and built
out our clinic space as the building development
was completed. We were the only tenants in the
building for the first year, which certainly did not
help us grow any faster.
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The next puzzle piece was partnering with
an orthopedic surgeon or group of surgeons who
would support our concept. We felt strongly that
we had a story worth telling and an idea that would
lead to a friendly and natural referral source for new
surgery referrals. Our experience told us that most
surgeons are happiest in the operating suite and
prefer to let a PA handle office visits. We were very
fortunate to partner with Premier Orthopedics and
Sports Medicine, the finest orthopedic group in the
Middle Tennessee area, giving us access to a group
of 28 surgeons in various orthopedic subspecialties
to whom we refer patients in need of surgery.
Our attorneys negotiated an affiliation agreement
between our organizations and we settled on
a rotation of four orthopedic surgeons coming
through our clinic each week to meet patients
for surgical referrals, follow-up on post-surgical
patients, handle Medicare patient referrals, and
meet the rare patient who only wants to be seen
by a medical doctor.
In August 2006, Seven Springs Orthopaedics
and Sports Medicine was established and we
opened our doors for service. On day one, not a
single patient darkened our doors for treatment.
Talk about nerves! On day two, we treated three
patients. The story continues with slow, steady
growth from that date forward. In February 2009,
we opened our second location approximately 24
miles away, and both locations are now thriving
with patient flow and an ever-growing referral
network. We have had over 20,000 new patients in
just over 6 years.
We feel thoroughly blessed and know that
we must continuously work harder than other
orthopedic groups to maintain a high level of
service to the community and our referral network
to keep everyone satisfied. We feel that we must
prove ourselves daily by offering better quality
and speed of service than any of our competitors.
Every Monday through Friday, we offer same-day
appointments, with the office notes from each visit
faxed to the referring physician the very next day
so communication is fast and accurate.
A venture of this magnitude is not without
challenges. We often feel that our challenges are
moving targets and we have to be nimble to adjust
our tactics successfully. Since a PA-owned clinic
had never been done before, we had no standard
to which we could compare ourselves. We were
setting the standard, which can be challenging in
and of itself.
Every day, we wear many hats. First, we
are PAs and have to meet the high standards of
our profession to practice medicine with proper
supervision. Our surgeons review our office notes
and x-rays each day. We made an extra investment
in digital x-ray capabilities so that an offsite
surgeon can review x-rays immediately to make
critical decisions regarding patient care. We meet
regularly with our surgeons to ensure that we are
meeting their expectations for patient care. These
meetings have developed a wonderful working
relationship with reciprocating respect and trust.
What does the future hold? Without a
doubt, more change. Some of the changes will
be out of our control, such as the effects of the
Affordable Care Act, and we must maneuver to
meet the requirements of those new regulations.
Other changes we can control and those are
very exciting to plan and implement. We want to
continue to improve our current clinics to become
more efficient and treat more patients in the years
ahead. We want to hire more PAs to join the Seven
Springs Orthopaedics and Sports Medicine family.
We have long-term plans to add more clinics and
to work with more surgeons. We want to move
into a consulting role and help other PAs navigate
the challenges of becoming clinic owners and
operators. The possible directions of this venture
are endless and thrilling to contemplate.
Just as the seasons change and the days on
the calendar tick by, our lives and careers change
and can become something very different than we
intended. When I enrolled in graduate school to
become a PA, I never imagined owning and operating
my own orthopedic clinics. I hope this article
sparks an interest in exploring the possibilities of
change in your career path, which may afford you
the same opportunities to own a clinic in the years
ahead. It is a very difficult mountain to climb, but
when you reach the peak and look back at the path
you conquered and all you accomplished, as well
as consider what possibilities lie ahead, it is well
worth the risks and efforts required.
The author has no relationship to disclose relating to the
content of this article
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JOPA 35
Nonoperative Treatment
of Knee Osteoarthritis
It is common to see patients in the clinic complaining of knee pain, many
of whom have osteoarthritis (OA). Most patients with knee OA can initially be
treated successfully with nonoperative modalities, although eventually, surgical
treatment may be necessary to resolve symptoms. Medicare requires increasingly
stringent documentation of nonoperative treatment failures prior to approving
payment for arthroplasty procedures. It is no longer sufficient to dictate that a
patient “failed nonoperative treatment for knee OA and is ready to proceed with
total knee arthroplasty.” Hospital records must indicate the duration, specific
types, and outcomes of nonoperative treatments that have been performed.
Specific functional limitations and activity modifications should be documented
in the hospital chart. A minimum of 3 months of nonoperative management
needs to be documented in the patient’s history and physical.
What nonoperative treatments are most beneficial to patients? In 2009, the
American Academy of Orthopaedic Surgeons (AAOS) published clinical practice
guidelines, based on the available literature, that address the effectiveness of
various knee OA treatments.1 These guidelines provide recommendations for or against interventions based
on evidence available for each treatment. Evidence for each intervention is graded on different levels: Level
1 has good evidence of effectiveness, Levels 2 and 3 have fair evidence, and Levels 4 and 5 show poor-quality
evidence. An inconclusive recommendation is made when insufficient or conflicting evidence is available.
Recommendations for each intervention are given a final grade: A for recommended, B for suggested, C for
optional, and Inconclusive for neither recommended nor not recommended. Other guidelines have been
published by the Osteoarthritis Research Society International2-3 and the American College of Rheumatology4.
This article summarizes current recommendations and provides scientific rationale for the use of nonoperative
treatments.
WEIGHT LOSS
The average American weighs more today than 10 years ago. According to data from the Centers for
Disease Control, over one-third of adults in the United States are obese. In 2004, only nine states reported
that more than 25% of their population was obese (body mass index >30); in 2010, this number rose to 35
states.5 Obese patients are more likely to undergo joint replacement at a younger age.6 Does excessive weight
make an already arthritic joint more painful or does it directly damage the joint? The answer is probably
both. Massive weight loss after bariatric surgery has been shown to significantly reduce pain associated with
osteoarthritis.7 In fact, some studies indicate a possible cellular cause of cartilage breakdown associated with
OA in obese patients.8-9 Although weight loss can reduce symptoms, it will not repair the damage to articular
cartilage.
The AAOS clinical guidelines recommend that patients with osteoarthritis and a body mass index
greater than 25 are encouraged to lose a minimum of 5% of their body weight and to maintain the weight loss
through diet and exercise (Level I evidence, Grade A recommendation).1 This recommendation is based on
randomized controlled studies that demonstrate a reduction in arthritic symptoms with weight loss.10
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Figure 1. Non weight-bearing AP view
Figure 2. Weight-bearing AP view
Figures 1 and 2 illustrate the importance of obtaining weight-bearing films to accurately depict joint space narrowing
and OA severity. Figure 2 shows an increase in medial joint space narrowing and varus deformity with weight-bearing.
PHYSICAL THERAPY
A structured exercise program or physical therapy is commonly recommended for patients with knee
OA. Patients often question whether this is useful and may complain about the high cost of their co-payment.
Certainly, patients who demonstrate weakness of the quadriceps and hamstrings, gait abnormalities, and/or
poor balance will benefit from a strengthening program. A structured physical therapy program encourages
compliance with exercises and ensures that they are performed safely. Periarticular muscle strengthening
and stretching helps maintain and improve joint mobility and increases joint stability. The AAOS clinical
guidelines recommend low impact aerobic exercise (Level I evidence, Grade A recommendation). The benefits
of quadriceps strengthening (Level II evidence, Grade B recommendation) and range of motion exercises
(Grade C recommendation) are less evident.1
ASSISTIVE DEVICES
Many patients with arthritis do not wish to use a cane or a walker, as they do not want to appear
disabled. Elderly patients often consider not using assistive devices a point of pride. However, if used
correctly, a cane or a crutch in the opposite hand as the affected joint will reduce joint reactive forces.11 A
walker can also improve balance and may be easier for some patients to use.
BRACING
Many different types of braces can be used for OA, such as a simple wrap, tape placed on the knee,
and metal-hinged custom-fitted braces. Orthotics can also be placed in the shoe to modify gait patterns.
Patients often like braces because they feel that the brace gives them support. In fact, many patients report
pain relief and improved function with bracing.12 The effectiveness of braces, however, is not universally
agreed upon and they are often expensive. Neoprene braces are thought to provide warmth and support to
muscles; however, a recent study found that vastus medialis muscle activation during squatting decreased
while using a brace.13 Additionally, if patients find braces uncomfortable or ineffective, they will stop using
them. For example, one study of patients prescribed medial unloader braces for OA found that after 2 years,
JOPA 37
only 25% of patients were still using the brace.14 The AAOS clinical guidelines also show modest support for
patellar taping (Level II evidence, Grade B recommendation), but did not feel that sufficient evidence existed
to give support for or against the use of unloader style braces. Well designed, randomized studies are needed
to determine the effectiveness of bracing. Finally, strong recommendations against the use of lateral heal
wedges were made because of limited data showing effectiveness.1
MEDICATIONS
Commonly prescribed medications for knee OA include acetaminophen, oral and topical non steroidal
anti-inflammatories (NSAIDs), and COX-2 selective inhibitors. A Cochrane review of randomized controlled
studies found that both acetaminophen and NSAIDS significantly improve pain relief in knee arthritis compared
to placebo. Acetaminophen has a lower associated risk of complications,whereasNSAIDS appear to be more
effective for pain relief.15 The U.S. Food and Drug Administration (FDA) recently lowered the recommended
maximum dose of acetaminophen to 3g per day to reduce the risk of accidental overdose and subsequent
liver damage. NSAIDS are associated with risks of gastrointestinal (GI) bleeding and kidney damage, and long
term use may have negative effects on the cardiovascular system. GI bleeds remain the most common side
effect of NSAIDS. Risk factors for GI bleeds in patients using NSAIDs include an age over 60 years, alcohol
or tobacco use, a history of peptic ulcer disease or prior GI bleeds, and concomitant use of oral steroids or
anticoagulants. Combination treatment with proton pump inhibitors (PPIs) and COX-2 inhibitors provides
the best protection against GI bleeding in high risk patients.16 Topical NSAIDS have also been shown, in some
randomized controlled studies, to be as effective as oral NSAIDs and they may have a lower associated risk of
GI side effects.17 Other topical agents such as methylsalicylates and capsaicin cream may be beneficial for
those who cannot tolerate, or choose to avoid, systemic therapies.
AAOS clinical guidelines support the use of acetaminophen and NSAIDs to treat knee OA (Level II
evidence, grade B recommendation). For patients greater than 60 years of age or at increased risk of GI
bleeding, COX-2 inhibitors, PPIs, and topical NSAIDs are recommended as well.1 Although some studies have
shown glucosamine and chondroitin sulfate to be effective for treating arthritis pain, AAOS clinical guidelines
strongly recommended against their use (Level I evidence, grade A recommendation).1 Tramadol may be
considered in patients with impaired renal function or who have failed prior oral therapies. For patients with
severe pain, more potent opioids may be used with caution to prevent tolerance, dependence, and associated
adverse effects.
STEROID INJECTIONS
Corticosteroid injections into the knee joint are a common treatment for knee OA. Pain relief is the
greatest during the first 4 weeks following the injection; however, this is accompanied by minimal change
in functional status.18 The usual recommendation is to perform injections no more frequently than every 3
months. In patients with OA, steroid injections every 3 months compared to a placebo for 2 years were found
to be safe, provide pain relief, and were not associated with progression of OA.19 Basic science research
and clinical reports indicate that steroids may damage chondrocytes, although it is unclear if this is related
to the steroid itself or to the local analgesic agents that are often administered concurrently.20 Therefore,
intra-articular steroid injections should be used cautiously or not at all in patients with knee pain but without
significant arthritic changes. AAOS clinical guidelines recommend the use of corticosteroid injections for
knee OA (Level II evidence, grade B recommendation).1
VISCOSUPPLEMENTATION
Viscosupplementation with hyaluronic acid (HA) is an FDA approved medical device used for treating
knee OA. A healthy knee contains 2 ml of synovial fluid, with an HA level of 2.5 to 4 mg/ml. The concentration
and molecular size of HA is decreased in arthritic knee joints, resulting in lower dynamic viscous and elastic
properties of the synovial fluid. Viscosupplementation was developed to preserve the lubricating and shock
absorbing properties of healthy synovial fluid, properties that are essential for maintaining the integrity of
38
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articular surfaces. Intra-articular administration of HA has also been found to reduce inflammatory mediators,
diminish pain signals, and it might stimulate synovial fibroblasts to produce HA.21
The efficacy of HA injections have been evaluated in several studies. A large systematic review
published in 2006 found beneficial effects in pain, function, and global assessment, especially during the
5- to 13-week post-injection period.22 A meta-analysis published in 2004 found significant improvements in
pain and functional outcomes in the treatment of patients with knee OA. However, patients with advanced
radiographic osteoarthritic changes were less likely to benefit from HA injections.23 A number of different
HA products exist today, many of which differ in molecular weight, dosage per injection, and recommended
number of injections. Repeated courses are generally effective and well tolerated; efficacy is typically
determined by the severity and progression of OA. One meta-analysis suggests that pain relief following
viscosupplementation may be longer lasting than with corticosteroids.24 Current research is exploring the
chondro-protective properties of HA and the potential analgesic properties for acute chondral injuries and
post-arthroscopy pain. AAOS clinical guidelines found data on viscosupplementation to be inconclusive due
to study methodology and the manner in which the studies were pooled for the meta-analysis. They were
therefore unable to make a recommendation for or against the use of viscosupplementation.1
CONCLUSIONS
There are many nonoperative treatment options for patients with OA, most of which provide
symptomatic relief. However, none of these treatments prevent progression of OA. Although some patients
get long-lasting relief with nonoperative measures, many will have progressive limitations to their ability to
ambulate and perform activities of daily living and will require surgical treatment. Additionally, it is important
to document all nonoperative interventions before proceeding with joint replacement surgery.
Dr. Hogan is a consultant for Cadence Pharmaceuticals and Ferring Pharmaceuticals.
References
1. Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the
knee (nonarthroplasty).J Am Acad Orthop Surg. 2009;17(9):591-600.
2. Zhang W, Moskowitz RW, Nuki G, Abramson S, et al. OARSI
recommendations for the management of hip and knee osteoarthritis, Part II:
OARSI evidence-based, expert consensus guidelines.Osteoarthritis Cartilage.
2008;16(2):137-62
3. Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for
the management of hip and knee osteoarthritis: part III: Changes in evidence
following systematic cumulative update of research published through
January 2009. Osteoarthritis Cartilage. 2010;18(4):476-99.
4. Hochberg MC, Altman RD, April KT, Benkhalti M, et al. American College
of Rheumatology 2012 recommendations for the use of nonpharmacologic
and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
Arthritis Care Res (Hoboken). 2012;64(4):465-74.
5. Centers for Disease Control and Prevention. Adult Obesity Facts. http://
www.cdc.gov/obesity/data/adult.html. 2/26/13.
6. Changulani M, Kalairajah Y, Peel T, et al. The relationship between obesity
and the age at which hip and knee replacement is undertaken. J Bone Joint
Surg Br. 2008;90(3):360-3.
7. Edwards C, Rogers A, Lynch S, et al. The effects of bariatric surgery
weight loss on knee pain in patients with osteoarthritis of the knee. Arthritis.
2012;2012:504189.
8. Rojas-Rodríguez J, Escobar-Linares LE, Garcia-Carrasco M, et al. The
relationship between the metabolic syndrome and energy-utilization deficit
in the pathogenesis of obesity-induced osteoarthritis. Med Hypotheses.
2007;69(4):860-8.
9. Hui W, Litherland GJ, Elias MS, et al. Leptin produced by joint white
adipose tissue induces cartilage degradation via upregulation and activation of
matrix metalloproteinases. Ann Rheum Dis. 2012;71(3):455-62.
10. Christensen R, Bartels EM, Astrup A, et al. Effect of weight reduction in
obese patients diagnosed with knee osteoarthritis: a systematic review and
meta-analysis. Ann Rheum Dis. 2007;66(4):433-9.
11. Simic M, Bennell KL, Hunt MA et al. Contralateral cane use and knee
joint load in people with medial knee osteoarthritis: the effect of varying body
weight support. Osteoarthritis Cartilage. 2011;19(11):1330-7.
12. Briggs KK, Matheny LM, Steadman JR. Improvement in quality of life
with use of an unloader knee brace in active patients with OA: a prospective
cohort study. Knee Surg. 2012;25(5):417-21.
13. Choi EH, Kim KK, Jun AY et al. Effects of the off-loading brace on
the activation of femoral muscles -a preliminary study. Ann Rehabil Med.
2011;35(6):887-96.
14. Squyer E, Stamper DL, Hamilton DT, et al. Unloader Knee Braces for
Osteoarthritis: Do Patients Actually Wear Them? Clin Orthop Relat Res. 2013
Feb 2.
15. Towheed TE, Maxwell L, Judd MG, et al. Acetaminophen for
osteoarthritis. Cochrane Data- base Syst Rev. 2006;Jan 25;(1).
16. Chan FK, Wong VW, Suen BY, et al. Combination of a cyclooxygenase-2 inhibitor and a proton- pump inhibitor for prevention of
recurrent ulcer bleeding in patients at very high risk: a double-blind,
randomized trial. Lancet. 2007;369(9573):1621-6.
17. Derry S, Moore RA, Rabbie R. Topical NSAIDs for chronic
musculoskeletal pain in adults. Cochrane Database Syst Rev. 2012 Sep 12;9.
18. Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G.
Intraarticular corticosteroid for treatment of osteoarthritis of the knee.
Cochrane Database Syst Rev. 2006 Apr 19;(2)
19. Raynauld JP, Buckland-Wright C, Ward R, et al. Safety and efficacy
of long-term intraarticular steroid injections in osteoarthritis of the knee:
a randomized, double-blind, placebo-controlled trial. Arthritis Rheum.
2003;48(2):370-7.
20. Syed HM, Green L, Bianski B, et al. Bupivacaine and triamcinolone
may be toxic to human chondrocytes: a pilot study. Clin Orthop Relat Res.
2011;469(10):2941-7.
21. Esdaile JM, Watterson JR. Viscosupplementation: Therapeutic
Mechanisms and Clinical Potential in Osteoarthritis of the Knee. J Am Acad
Orthop Surg. 2000;8(5):277-84.
22. Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G.
Viscosupplementation for the treatment of osteoarthritis of the knee.
Cochrane Database Syst Rev. 2006;Apr 19;(2).
23. Chen-Ti Wang; Jinn Lin; Chee-Jen Chang; Yu-Tsan Lin; Sheng-Mou
Hou. Therapeutic effects of hyaluronic acid on osteoarthritis of the knee. A
meta-analysis of randomized controlled trials. J Bone Joint Surg Am. 2004;86A(3):538-45.
24. Bannuru RR, Natov NS, Obadan et al. Therapeutic trajectory of
hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: a
systematic review and meta-analysis. Arthritis Care Res. 2009;61:1704–11.
JOPA 39
Physical Therapy Corner
The Graston® Technique and Treatment
of Soft Tissue Dysfunction
• Plantar fasciitis
• Cervical pain
• Epicondylitis
• Muscle strains
Karin Biskovich, MPT
Apple Therapy Services, Amherst, NH
Certified Graston® Provider
I treated a patient with Achilles tendonosis 5
years ago. He was referred to me because he had an
injury to his Achilles tendon that was non-surgical
and limited his ability to walk with a normal gait and
participate in his recreational hobbies. After a few
sessions of trying aggressive cross-friction work to
the tendon, the patient reported improvement and
pain reduction with walking and tendon stretch.
However, I had difficulty performing the treatment
because my hands fatigued quickly.
During my care of this patient, I attended
a continuing education conference and learned
about instrument-assisted soft tissue mobilization
(IASTM) techniques. Shortly thereafter, I attended
a training session for the Graston® Technique,
one form of IASTM, and purchased the required
instruments. I quickly observed the benefits of
adding this technique to my treatment plans,
and I now find it effective for the treatment of the
following soft tissue dysfunctions:
• ITB syndrome
• Achilles tendonitis
• Patellofemoral syndrome
• Patella tendonitis
• Painful scars
The technique uses six stainless steel
instruments with concave/convex shapes to
match the different parts of the body. Using the
curvilinear edges of the metal instruments, I am
able to detect fascial restrictions that inhibit the
lengthening of the muscle and limit recovery. The
Graston Technique tools act as focused extensions
of my hands.
Performing the Graston Technique in
conjunction with a specific stretching, selfmyofascial mobilization, and strengthening
program helps my patients reduce their pain
level and often continue their activities as well. In
particular, I am able to use the Graston Technique to
treat patients in positions of symptom provocation
and with movement.
I have been a therapist in an outpatient
orthopedic setting for 10 years and have used the
Graston Technique for 3 years. I believe that the
Graston Technique allows me to offer patients a
more effective tool for their care that allows them
to return to their activities more quickly.
The author has no relationships to disclose relating to the
content of this article.
• Low back pain
Clinical Pearl
A transcutaneous electrical nerve stimulation (TENS) unit
uses electrodes to deliver a light current to the skin and
us
underlying tissues. Electrodes send stimulating pulses to
un
help prevent pain signals from reaching the brain.
he
40
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JOPA
Sideline Diagnosis and Management of
Sports-Related Concussions
Tyler Kimbar, AT-C
Performance Rehab, Nashua, NH
Concussions are among the most difficult sportsrelated injuries to diagnose and manage. No imaging
techniques that can accurately determine whether
a person has a concussion are currently available,
making a diagnosis almost entirely subjective1.
Each athlete will have unique symptoms and react
differently to each concussion.
Misguided by a fear of missing games, many
athletes and some coaches try to hide symptoms so
that the athlete can continue playing. If an athlete
has had a previous concussion, the severity of a
new concussion is instantly increased. With more
research published every day regarding the shortand long-term effects of concussions, it is essential to
recognize key signs and symptoms and know what to
do when someone has a concussion. Education and
a fast response time are vital for sideline concussion
management.
The incidence of concussions is highest in
American football, with approximately 250,000
concussions and an average of eight associated
deaths in teen athletes annually2. Concussions are
caused by linear and/or rotational forces that are
sent through the brain, either by a traumatic or nontraumatic injury3. Immediately following an injury,
ionic shifts occur at the cellular level, leading to
acute and subacute changes. Acutely, stretching of
nerve fibers results in a cellular shift of potassium
and calcium ions. Sodium/potassium pumps work
harder to restore membrane potential, resulting in
an increased glucose demand. This increased energy
demand is accompanied by a decrease in cerebral
blood flow, which creates an energy crisis and
diminished brain function. Subacutely, persistently
elevated levels of intracellular calcium ions impair
neural connectivity and can lead to cell death4.
The first part of sideline concussion management
is making sure the cervical spine is clear of any
injuries. Any palpable pain over the cervical spine
with numbness or tingling in the extremities,
requires cervical stabilization and transportation by
emergency medical services to a hospital. In case of
a suspected cervical injury, it is imperative to leave
the player’s helmet on, keeping the cervical spine in
neutral alignment to limit cervical motion, and only
remove the face mask to maintain a proper airway.
The helmet should only be removed if cardiovascular
or respiratory distress is present or stabilization
cannot be maintained due to poor fit. If the helmet
is dislodged during injury, placing a folded towel
under the player’s head can help maintain neutral
alignment of the cervical spine5. After the cervical
spine is cleared, evaluation of current symptoms is
necessary.
Common concussion symptoms may include
but are not limited to headache, dizziness, nausea,
tinnitus, sensitivity to light or sound, delayed
responses, a feeling of fogginess, slurred speech,
nystagmus, balance problems, and drowsiness6.
Loss of consciousness (LOC) is not required for an
injury to be considered a concussion, and unless
the duration is greater than 1 minute, LOC is not an
indicator of concussion severity1. A common sideline
“pocket” test that can be used during a game or
practice is the Sport Concussion Assessment Tool 2
(SCAT2), which includes a standard list of questions
for checking symptoms and memory function and an
objective balance test1.
Evaluations and questioning should happen
every 5 minutes to ensure that symptoms are not
worsening and the athlete is not deteriorating. If any
symptoms worsen, the athlete must be immediately
transferred to a hospital1. Observe and note how the
athlete answers questions and try to determine if
JOPA 41
responses are delayed while checking short- and longterm memory and the ability to focus. More severe
symptoms like retrograde and anterograde amnesia
lasting more than 15 minutes, anisicoria, excessive
vomiting, LOC, deterioration of symptoms, trouble
staying lucid, and any blood or cerebrospinal fluid
leaking from the ear canal may indicate a potentially
life-threatening condition. Anisocoria is a possible
indicator of a subdural or epidural hematoma, which
if left untreated could lead to death1. These symptoms
may not be apparent for hours or days after the initial
injury and should not be missed during a thorough
examination.
Cranial nerve assessments can be used to
determine if any deficits due to increased intracranial
pressure from a concussion are present. Pupillary
reaction, balance, sensation, and motor function
can all be tested during a cranial nerve assessment.
Testing dermatomes and myotomes may also be
helpful in finding neurological deficits.
When taking the athlete’s history, previous and
recent concussions must be carefully considered.
Second-impact syndrome (SIS) happens when
an athlete sustains a second concussion before
symptoms of a prior concussion have subsided. SIS
is more common in teenagers and is characterized
by rapid swelling of the brain that causes sudden
and severe loss of neurological function. Nearly 50%
of SIS cases lead to death, and 100% result in brain
damage2. Thus, recognizing concussion symptoms
and preventing an injured athlete from returning too
early are crucial.
Numerous grading scales for concussions
have been reported, but none are widely accepted.
However, most scales do agree on the use of LOC
and amnesia as determining factors for grading.
The American Academy of Neurology uses grades
1-3 based on LOC and symptoms of confusion. Mild
or grade 1 is associated with no LOC and confusion
lasting less than 15 minutes, moderate or grade 2
involves no LOC with confusion lasting greater than
15 minutes, and with a severe or grade 3 concussion,
LOC does occur. The Cantu Grading Scale has a
similar 1-3, or mild, moderate, and severe, grading
system. Grade 1 is associated with no LOC and postinjury amnesia less than 30 minutes, grade 2 involves
LOC for less than 5 minutes with amnesia lasting less
than 24 hours, and grade 3 involves LOC greater than
5 minutes with post-traumatic amnesia lasting over
24 hours. Although no grading scales are currently
42
JOPA
widely accepted, LOC greater than 1 minute and posttraumatic amnesia lasting longer than 30 minutes are
understood to be signs of more severe concussions5.
Athletes will sometimes try to withhold, hide,
or disguise symptoms so they can continue to play,
making a thorough exam critical. Continually checking
symptoms until the athlete is in stable condition is
vital. Athletes who experience concussion symptoms
should not return to play on the same day. A full
neuropsychological exam and a symptom-free,
progressive cardio workout should be required
before returning to sports.
Education plays an important role in sideline
management of concussions. It is essential for the
health care provider to remain accessible to the
injured player and the injured player’s family until
they seek further medical attention. Providing
written and oral instructions to an injured athlete can
increase compliance by 55% following a concussion3.
Diagnosing and managing concussions from
the sidelines are difficult tasks that cannot be taken
lightly. Research studies concerning concussion
diagnosis, management, and long-term effects
continue to be published. Many leaders in concussion
research gathered at the fourth International
Conference on Concussion in Sport in November,
2012 in Zurich, Switzerland, which was organized
with assistance from sports organizations including
the International Olympic Committee, International
Ice Hockey Federation, Fédération Internationale
de Football Association, International Rugby Board,
and Fédération Equestre Internationale. New findings
from this conference will be published in the early
months of 2013.
The author has no relationships to disclose relating to the
content of this article.
References
1. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M,
Cantu R. Consensus statement on concussion in sport-the Third International
Conference on Concussion in Sport held in Zurich, November 2008. Phys
Sportsmed. 2009;37(2):141-159.
2. Durand P, & Adamson GJ. On-the-field management of athletic head
injuries. J Am Acad Orthop Surg. 2004;12(3):191-195.
3. Scorza KA, Raleigh MF, O’Connor FG. Current concepts in concussion:
evaluation and management. Am Fam Physician. 20112;85(2):123-132.
4. Giza C, Hovda D. The Neurometabolic Cascade of Concussion. J Athl Train.
2001;36(3): 228–235.
5.Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly JP, McCrea M,
Putukian M, Valovich McLeod TC. National Athletic Trainers’ Association
position statement: management of sport-related concussion. J Athl Train.
2004;39(3):280-297.
6. Harmon KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M,
Herring SA, Roberts WO. American Medical Society for sports medicine
position statement: concussion in sport. Br J Sports Med. 2013;47(1):15-26.
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JOPA 43
balance
between science
and nature.
Restoring the
t
ORTHOVISC® High Molecular Weight Hyaluronan is the only non-avian
hyaluronic acid (HA) with up to 26 weeks of efficacy1
t
ORTHOVISC® demonstrated statistically and clinically significant
symptom improvement in patients with knee osteoarthritis1
ORTHOVISC® has
50-88%
more HA2-6
than any available
viscosupplement
1-800-382-4682 | www.orthovisc.com | www.orthoviscline.com
Important Safety Information
ORTHOVISC® High Molecular Weight Hyaluronan is indicated in the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to
respond adequately to conservative nonpharmacologic therapy and to simple analgesics, e.g., acetaminophen. In clinical studies, the most commonly
reported adverse events were arthralgia, back pain, and headache. Other side effects included local injection site adverse events. ORTHOVISC® is
contraindicated in patients with known hypersensitivity to hyaluronate formulations or known hypersensitivity (allergy) to gram positive bacterial proteins.
ORTHOVISC® should not be injected in patients with infections or skin diseases in the area of the injection site or joint. Strict aseptic technique should
be used. The effectiveness of more than 1 course has not been established.
References: 1. Brandt KD, Block JA, Michalski JP, et al. Efficacy and safety of intraarticular sodium hyaluronate in knee osteoarthritis. Clin Orthop Relat Res. 2001; 385:130-143.
2-6. Manufacturer’s full prescribing information for ORTHOVISC®, Synvisc®, Synvisc-One®, Hyalgan®, Supartz®, and Euflexxa.TM
Hyalgan is a registered trademark of Sanofi-Synthelabo; Supartz is a registered trademark of Seikagaku Corporation; Synvisc and
Synvisc-One are registered trademarks of Genzyme Corporation; Euflexxa is a trademark of Ferring Pharmaceuticals, Inc.
ORTHOVISC® is manufactured by and is a registered trademark of Anika Therapeutics, Inc., Bedford, MA 01730.
© DePuy Synthes Mitek Sports Medicine, a division of DOI 2013. All rights reserved. Printed in USA.
44
JOPA