Dr Philip Wrotslavsky's space

1. Performing immediate surgery is not standard practice in the treatment of any lateral ligament sprain in the competitive athlete.  The literature continues to demonstrate that, regardless of extent of ligament injury, athletes will respond as well or better to a functional rehabilitation program compared to open surgical repair.  In the NFL and the NBA, immediate repair of acute ankle ligament ruptures are never done, period.

2. Data from the NCAA has demonstrated that the average time of return to play after Grade-2 ligament sprain in the ankle is 10 days.

3. The suggestion of performing a local anesthetic block to a sprained ankle prior to return to play would not ever be done by any credible medical team managing a professional athlete. Yes, proprioception would be even further compromised.

4. There is no official word on the true extent of ligament injury sustained by Dwight Freeney. The video tape replay shows a mild plantarflexion-inversion injury with minimal ankle rollover.

From http://www.npr.org/blogs/health/2010/02/wii_injury_balance_board.html?sc=fb&cc=fp

Over the years we've broken bones and hurt ourselves in all sorts of embarrassing ways. But so far, knock on wood, we haven't done any damage while playing a video game.

The opportunity for trouble is surely there, as an English doctor writes in the latest issue of the New England Journal of Medicine. A 14-year-old girl showed up at the emergency room after falling off a Wii Fit balance board and twisting her ankle very badly.

Her right foot was swollen and painful. An X-ray found she'd fractured a long bone in her foot that's connected to the little toe. Isn't that the one that goes "Wiiiiiiiii" all the way home?

Seriously, the doctors figure a muscle pulled so hard on the bone during her fall that it broke, a common injury in other more traditional sports.

In a statement, Nintendo of America said:

The Wii video game system is often credited with getting people up off the couch. But, as with any new activity, people playing the Wii system should pace themselves and not overdo it. Nintendo is committed to the safety of its consumers.

You can find Nintendo's general safety tips for Wii here.

We're all for the active exercise that Wii makes possible while staying warm in the basement this time of year. But be careful folks.

The balance board is just the latest factor in Wii-related injuries. Plenty of people have been hit by flying game controllers. Strains and dislocations are also not unheard of.

A recent roundup in a medicine journal found Wii Tennis was the most common game associated with injuries that people reported. Cuts to the hand were the most frequent problem.

Another case published last year involved a 38-year-old man who cracked a bone in his neck that appeared to be the result of "swinging his Wii game console control during a rather vigorous game." The break, called a "clay-shoveler's fracture," is usually associated with rapid heavy lifting.

Apparently even virtual sports can cause real injuries.

From http://www.npr.org/blogs/health/2010/02/wii_injury_balance_board.html?sc=fb&cc=fp

Approximately 4,400 patients are expected to undergo surgery to replace arthritic or injured ankles with artificial joints made of metal alloys and lightweight plastic this year, and demand is expected to increase as the Baby Boomer generation ages. Each year, approximately 2 million Americans visit the doctor for ankle pain from arthritis or fracture, and an estimated 50,000 people a year experience end-stage ankle arthritis. “For an ankle replacement you have to be a little more picky in who you select,” says Dr. Craig S. Radnay, an associate at the Insall Scott Kelly Institute for Orthopedics and Sports Medicine in New York who has performed more than 100 ankle replacements.

From the article of the same title
New York Times (01/18/10) Parker-Pope, Tara

Researchers report that an increasingly-used treatment method for chronic Achilles tendinopathy that includes injection of platelet-rich plasma into the tendon does not appear to result in greater improvement in pain or activity compared to placebo. An estimated 30 percent to 50 percent of all sports-related injuries are Achilles tendon disorders, according to the researchers. Approximately 25 percent to 45 percent of patients eventually require surgery following ineffective conservative treatment. “There is a clear need for improved conservative therapy,” say the researchers.

From the article of the same title
Journal of the American Medical Association (01/13/10) de Vos, Robert J.; Weir, Adam; van Schie, Hans T. M.; et al.

The FDA has issued a Medwatch Safety Alert that warns hospitals and long-term care facilities to be on the lookout for serious complications and risk of death resulting from use of negative pressure wound therapy (NPWT) systems that can cause fatal bleeding and infections. The alert was issued after the FDA received reports of six deaths and 77 injuries associated with NPWT systems over the past two years related to extensive bleeding involving vascular grafts, sternal and groin wounds, anti-coagulant therapy, and the removal of dressings. More information can be found at
http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMe
dicalProducts/ucm190704.htm.

From the article of the same title
HealthLeaders Media (01/08/10) Clark, Cheryl

ACFAS offers mothers-to-be remedies for aching feet

"Oh my aching feet" is a phrase you hear often from pregnant women. But are sore feet a symptom they just must deal with during pregnancy? According to the American College of Foot and Ankle Surgeons (ACFAS) the answer is "no." There are many remedies available to help alleviate foot pain.

Women often experience foot pain during pregnancy because of increased weight, foot instability and swelling. In the last five years, I've seen an increase in pregnant women with foot pain because more women than ever before are active, even running marathons, during their pregnancies, I  recommend the following guidelines to help reduce foot pain during pregnancy.

Painful, Swollen Feet -- Pregnant women often experience throbbing, swollen feet due to excess fluid build up (edema) in the feet from the weight and position of the baby. To reduce swelling, put feet up whenever possible, stretch legs frequently, wear wide comfortable shoes and don't cross legs when sitting.

Arch Pain -- Pain in the arch can be due to both arch fatigue or over pronation (or the flattening of the arch). Over pronation occurs due to extreme stress to the ligament (the plantar fascia) that holds up the arch of the foot. The best way to prevent arch pain is to stretch daily in the morning and before and after any exercise, don't go barefoot and wear supportive low-heeled shoes.

Foot Cramps -- These painful cramps are caused by increased blood volume and high progesterone levels brought on by pregnancy. To prevent cramps, increase circulation by rotating ankles and elevating feet while sitting. If cramps persist, try a walk around the block and include daily stretching of the calf muscles.

Ingrown Toenails -- Excessive stress from tightly-fitting shoes causes painful ingrown toenails. Give your feet a break: wear wider shoes during the last trimester of pregnancy to avoid ingrown toenails. If you do experience an ingrown toenail, avoid attempting "bathroom surgery." Repeated cutting of the nail can cause the condition to worsen over time. It is best to seek treatment with a foot and ankle surgeon.

It is also not uncommon for women to experience a change in their foot size during pregnancy. A permanent growth in a women's foot, up to half a size, can occur from the release of the same hormone, relaxin, that allows the pelvis to open to deliver the baby. It makes the ligaments in your feet more flexible, causing feet to spread wider and longer.

Pregnancy and pending motherhood should be a joy. If foot pain persists, a visit to a foot and ankle surgeon can provide relief with conservative treatments such as physical therapy, foot orthotics, supportive shoes and minor toenail procedures.

For more information on foot and ankle problems, visit FootHealthFacts.org.

The American College of Foot and Ankle Surgeons is a professional society of 6,000 foot and ankle surgeons. Founded in 1942, the College's mission is to promote research and provide continuing education for the foot and ankle surgical specialty, and to educate the general public on foot health and conditions of the foot and ankle through its consumer Web site, FootHealthFacts.org.

The California Department of Managed Health Care has issued new regulations that require physicians participating in HMOs to see patients within a certain number of days. The regulations require a 10-day maximum wait time for primary care and 15-day wait for specialists. Urgent care that does not require prior authorization must be provided within 10 days. From the article of the same title Los Angeles Times (01/19/10) Helfand, Duke

Why wait 15 days to come see a foot specialist, when you can be seen at The Advanced Foot and Ankle Center of San Diego within 3 days.

The FDA has approved Actemra for moderate to severe rheumatoid arthritis for patients not responding to TNF inhibitors. Actemra, given by once-monthly hour-long infusions, is the first IL-6 inhibitor for arthritis. Actemra cannot be given in combination with TNF inhibitors or other biologic treatments for arthritis, but it can be used in combination with disease-modifying drugs such as methotrexate.

From the article of the same title
WebMD (01/11/10)

From JAMA 2010;303(2):144-149.

http://jama.ama-assn.org/cgi/content/abstract/303/2/144?etoc

Tendon disorders comprise 30% to 50% of all activity-related injuries; chronic degenerative tendon disorders (tendinopathy) occur frequently and are difficult to treat. Tendon regeneration might be improved by injecting platelet-rich plasma (PRP), an increasingly used treatment for releasing growth factors into the degenerative tendon.

Objective To examine whether a PRP injection would improve outcome in chronic midportion Achilles tendinopathy.

Conclusion Among patients with chronic Achilles tendinopathy who were treated with eccentric exercises, a PRP injection compared with a saline injection did not result in greater improvement in pain and activity.

Need I explain?

German researchers used a fixed-angle plate osteosynthesis to treat 25 patients with closed distal tibial fractures, and a follow-up exam was conducted after an average of 16.6 months for all patients. Most patients achieved bone consolidation and full weight bearing after an average of 3.5 months. For all patients, the ankle range of motion was flexion/extension 18 degrees/35 degrees without restrictions on the walking distance, on average. The research supports the concept of fixed-angle plate osteosynthesis being a solid alternative to intramedullary nailing when treating closed distal lower leg fractures.

From the article of the same title
European Journal of Trauma and Emergency Surgery (11/17/09) Faschingbauer, Maximilian; Kienast, Benjamin; Schulz, Arndt P.; et al.

The Question is Too much cushion or too little. While cushioning and shock-absorption by a running shoe appears to be the biggest priority for shoe developers, use of an overly cushioned shoe can interrupt the process whereby the body is optimally “tuning” itself for ground impact. A running shoe that is too soft can overly-stiffen the muscle-tendon complex and create problems for an individual. I often hear of complaints from athletes that they cannot “feel” the ground and their joints – particularly knees and hips – feel stiff when wearing well-cushioned shoes. Problems can also be found with shoes that are overly stiff or supportive. Again, the foot and musculature cannot properly adapt to the surface upon which it is traveling, leading to higher impact forces and more problems with injury

Researchers at the 25th Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society presented research showing that patients with failed total ankle replacements converted to ankle or extended hindfoot fusions can benefit from large structural bone grafts, which have shown high union rates. The functional improvement is modest, the importance of preserving the subtalar joint as much as possible to improve function and limit complications. In a group of 24 patients who had failed total ankle replacements converted to fusion with structural allografts, all patients eventually achieved union though there were two nonunions, two soft-tissue complications, and three subtalar nonunions. The subtalar nonunions is a concern ,I recommend using a single anterior approach and IM nails in these instances.

From the article of the same title
Orthopedics Today (12/09) No. 29, P. 10; Brockenbrough, Gina

http://advancedfootandanklesd.com/default.aspx

A group of researchers performed a study to ascertain how useful clinical imaging is in anticipating the mechanical properties of Achilles tendons following an acute injury. They created a central tendon defect in one Achilles tendon of rabbits, which were then killed--some immediately after surgery, some four to eight weeks following surgery. The researchers carried out magnetic resonance imaging (MRI), ultrasonography (US), calcaneal bone mineral densitometry, and mechanical testing to failure by applying a dual-cryofixation assembly on experimental and contralateral tendons. Analysis via MRI and US showed that all dimensions of the injured tendons after two weeks and more were greater than those of the contralateral tendons. The tendons of rabbits that were killed four to eight weeks after surgery exhibited a greater average T1-weighted optical density (OD) than those in rabbits that were killed immediately after surgery. At both four weeks and eight weeks, mechanical stress was demonstrably lower in the experimental tendons compared to the contralateral tendons. Mean peak load to failure was substantially reduced immediately after surgery versus four and eight weeks afterward, and there was correspondence between lower mechanical stress and both high T1-weighted OD and proton density OD. There also was correlation between T1-weighted OD and reduced peak load in the experimental tendons. The investigators concluded from these findings that an enlarged tendon of lower stress tolerated normal peak loads four weeks after injury, which supports the notion that progressive loading is possible four weeks following a rupture to the Achilles tendon.

From the article of the same title
Medicine and Science in Sports and Exercise (11/09) Vol. 41, No. 11, P. 2009; Trudel, Guy; Doherty, Geoffrey P.; Koike, Yoichi; et al.

A study investigating the New Zealand experience with the three-part Scandinavian Total Ankle Replacement shows a 27 percent revision rate at five years. The researchers added that the implants that remain in situ result in generally good quality of life outcomes. The problem, common with all total ankle replacements, is the unpredictable outcome which can stem from inaccurate bone cuts and inferior matching of implants to bone.

From the article of the same title
Orthopedics Today (12/09) Brockenbrough, Gina

The Wright Inbone Total ankle replacement system

The Depuy total ankle replacement system

Negative pressure wound therapy (NPWT) used in combination with debridement and/or partial foot amputation may lead to successful limb salvage in patients with severe diabetic foot infections, according to research presented at the 25th Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society. In a review of 45 diabetic feet with limb-threatening infections that underwent debridement and/or partial amputation and NPWT using a vacuum-assisted closure (VAC), successful limb salvage was achieved in 97.8 percent of cases.

From the article of the same title
Orthopedics Today (12/09) Brockenbrough, Gina