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Paget’s Disease of the Bone

Paget disease of the bone is a chronic condition that causes the bones to become dense, enlarged and deformed, leading to fragile bones that fracture. It is the most common bone disorder after osteoporosis in adults after the age of 50. The risk of Paget’s disease of bone increases with age and with family history.

Bone remodeling is defined as a process in which new bone tissue replaces old bone tissue. This process is affected by Paget’s disease, resulting in dense but brittle bones.  It most commonly affects the pelvis, skull, spine, and legs. Complications of Paget’s disease of bone can include broken bones, hearing loss and pinched nerves in your spine.

There are two types of Paget’s disease of bone: monostotic (when only one bone is affected), or polyostotic (when multiple bones are involved).
Paget’s is also associated with neurologic complications, such as deafness, facial nerve palsies, radiculopathies, and spinal cord compression
The exact cause of Paget disease of the bone is not known, but genetics are thought to play a role.

There is some evidence that viral infection may also have a role in its development. Proteins derived from the respiratory syncytial virus and measles virus are present in pagetic osteoclasts. Paget’s disease tends to aggregate in families. First-degree relatives of patients with Paget ’s have a 7- to 10-fold increased risk of developing the condition.

While about 70% of patients with PDB are asymptomatic, in the remaining cases, it presents with joint inflammation, bone deformity, pain, and predisposition to fractures.

 

Paget’s disease can cause skeletal deformities, such as bowing of long bones, enlarged skull, pelvic alterations, and osteoarthritis. It can lead to traumatic and pathologic fractures. Very rarely, it can lead to osteosarcomas, which have a poor prognosis (5-year survival rate of approximately 10%). Paget’s is also associated with neurologic complications, such as deafness, facial nerve palsies, radiculopathies, and spinal cord compression. If it affects the skull, that can lead to hydrocephalus, nerve entrapment, and cerebellar dysfunction, causing the symptoms of nausea, ataxia, incontinence, gait disturbance, or dementia. It is also associated with high cardiac output, hypercalcemia, and hyperparathyroidism, but these are all rare.

 

Tests that can be done to confirm/support the diagnosis include:

  • Serum alkaline phosphatase: these levels are raised in any condition of bone growth or an increased activity of bone cells.
  • Bone scan: This is a nuclear imaging test that shows blood flow to the bone and cell activity within the bone, which helps determine areas of abnormally high bone turnover. It detects up to 50% more lesions than seen on x-ray films.
  • X-ray films: It is the main mode of its diagnosis. It shows osteolytic, osteoblastic, or mixed lesions. Other characteristic features include transverse lucent areas, enlargement of bones, expanding lytic changes, thickened cortices, or osteoporosis with lytic involvement in the skull.
  • Bone biopsy: These may be done to confirm the diagnosis through tissue assessment, but they are mostly done if the malignant transformation of the bone is suspected, which is characterized by cortical destruction and the presence of a soft tissue mass outside of the bone.

Treatment is targeted at suppressing osteoclastic activity.  The most commonly used agents are the bisphosphonates (such as Etidronate) that inhibit bone resorption. Intravenous options are also available, such as pamidronate. Salmon and human calcitonin are also FDA-approved and are given subcutaneously.

Occupational Repetitive Strain Injury

Repetitive strain injuries (RSI) are a group of disorders that most commonly develop in workers whose work involves excessive and repetitive motions of the neck and upper extremity. There are quite a few occupations that comprise such activities. It is also quite common in people involved in sports activities.

 

It all starts with taking a careful history, performing a proper physical examination and specific diagnostic maneuvers to detect these musculoskeletal injuries.

 

RSI may be present in a range of ways – cervical syndrome, tension neck syndrome, thoracic outlet syndrome, and frozen shoulder syndrome. Injuries involving the elbow, wrist and hand joints include epicondylitis, carpal tunnel syndrome and ulnar nerve entrapment.

RSI may also occur as a result of sports and recreational activities

RSI is especially common in all kinds of workplaces. The disorders of the forearm flexor tendons are most common among workers at assembly lines and trainees, whereas the cervical rotation and side-flexion are most affected in office workers. RSI may also occur as a result of sports and recreational activities. These injuries result from repetitive and forceful motions, awkward postures, and other sports/work-related conditions and ergonomic hazards.

 

Occupationally induced RSIs are costly, creating a strong incentive for physicians to become familiar with the symptoms, signs, and risk factors so that they can be diagnosed early and properly treated.

 

Hand/forearm-related RSI are common in office settings – such as carpal tunnel syndrome, cubital tunnel syndrome, Guyon canal syndrome, lateral epicondylitis, and tendonitis of the wrist or hand. The diagnosis is clinical but MRI and ultrasonography can be used for the diagnosis, but the role of such imaging in the diagnosis of upper limb disorders remains unclear. Once diagnosed, exercise can be beneficial for non-specific upper limb disorders. Other options, such as the immobilizing hand braces and open carpal tunnel surgery release are beneficial for carpal tunnel syndrome. Nonsurgical management, such as topical and oral non-steroidal anti-inflammatory drugs, and corticosteroid injections are helpful for lateral epicondylitis. Exercise is probably beneficial for neck pain, as are corticosteroid injections and exercise for shoulder pain.

 

In general, mainstay of treatment is mainly conservative and consists of rest, application of ice or heat and anti-inflammatory drugs. It typically takes a few or months to completely resolve.

 

It is very important to make necessary modifications in the workplace in order to prevent many of these injuries. Assessing the exposure of workers to known risk factors is essential The ergonomics of the workplace should properly be studied and accounted for in order to prevent workplace-related RSI. Training staff and performing necessary workplace changes would allow the staff to more effectively use their workplace through increased office ergonomics knowledge and skills. Once such training and interventions are in place, it leads to an increase in workers’ office ergonomics knowledge and awareness, and that results in a significant decrease in work-related musculoskeletal disorders.

 

RSI that is sports-related, can also be prevented by getting professional training to ensure the technique is right and the chance of injury is minimized.

Can PRP injections reduce my knee pain?

PRP or Platelet Rich Plasma injections are a hot topic among patients who are looking for ways to delay a knee replacement. If you are wondering how PRP can reduce your pain and help you return to an active lifestyle, read on.

Platelet Rich Plasma

Your blood contains a fluid component, or plasma and red cells, white cells and platelets. PRP refers to the plasma derived from your blood along with platelets. This plasma is prepared such that it carries more platelets in volume than your whole blood. The concentration of platelets in PRP can be 2-10 times that in the patient’s blood and more growth factors.

During an injury, platelets help the blood to clot and bring hundreds of proteins including anti-inflammatory and growth factors. All these factors initiate a healing response at the site of injury.

PRP Injections

When used as a knee injection, PRP can stimulate natural healing in the injured or inflamed knee environment.

A PRP injections is prepared by drawing blood from the patient and spinning it in a centrifuge to separate the platelets from other blood cells. The concentrated platelets and the plasma are prepared for injection.

Benefits of PRP Knee Injections

PRP injections have proven highly beneficial in treating knee injuries.

  • Reduction in knee pain without surgery
  • improved joint function

Side effects of PRP injections are very limited since the injection components come from the patient’s own blood.

Candidates for PRP injections

You could be a candidate for PRP knee injection if you have –

  • knee pain, due to osteoarthritis, that affects your daily activity
  • some joint space remains
  • pain is mainly due to the inflamed soft tissues rather than bone pain
  • conservative treatments, such as physical therapy, bracing and anti-inflammatory medications, have failed

To learn more about best knee replacement and treatments, consult the top orthopedic doctors in Gilbert, AZ, call OSPI Arizona at 480-899-4333. OSPI’s Board Certified orthopedic surgeons offer complete care and treatment for individuals in all stages of life, participating in all levels of activity.

Anxiety and Bone Health

Anxiety has already been known to be harmful to our body in many ways, such increased cardiovascular risks. It’s now becoming apparent that anxiety and persistent stress are linked to an increased risk of bone fractures in postmenopausal women as per a recently published study in the journal of The North American Menopause Society (NAMS).

Postmenopausal women are already prone to developing osteoporosis, for which they are prescribed vitamin D. Their risk of developing fractures is a major concern and this risk grows as they age. Stress and anxiety now add to this concern by adding another common predisposing factor.

Studies have shown that women with anxiety disorders were almost twice as likely to develop osteoporosis than were those without anxiety. High anxiety levels have been shown to be associated with low bone mineral density, which is a key indicator of fracture risk. The most common sites of osteoporotic fractures in these women are the lumbar spine and femoral neck.
In addition to these risk factors, cigarette smoking, sedentary lifestyle and prolonged use of steroids are major risk factors of osteoporosis-related increased fracture risk.

Anxiety may cause more oxidative stress, which may be related to osteoporosis in postmenopausal women
There are several ways anxiety may affect bone health. It is postulated that there may be some degree of systemic inflammation in people with high anxiety levels, which leads to bone loss. Anxiety and stress cause high cortisol levels in the blood, which has a known effect on bone demineralization and brittleness. Anxiety may cause more oxidative stress, which may be related to osteoporosis in postmenopausal women. To make matters worse, you may be more prone to falls if you have an anxiety disorder. Furthermore, some antidepressants may also cause a decrease in bone mineral density as well.

 

Based on this, it is becoming increasingly evident that mental issues, specifically anxiety and stress should be addressed in all patients – this is even more important in women postmenopausal age as stress and anxiety in this population can lead to significantly high fracture risk. Approximately 7% of the world suffers from an anxiety disorder, and it is as common in women. There is a link between anxiety and low vitamin D levels, which might explain the connection between anxiety disorder and bone fractures.

 

Women’s peak bone mass is said to be at age 35. Ever woman seeing a doctor should be screened for anxiety disorders and high-stress levels during their clinic visits. They should be taking 1200 mg of calcium a day in order to minimize the risk of developing osteoporosis. It is also important to have sufficient magnesium and vitamin D — from either sun exposure or supplements. Furthermore, having a healthy lifestyle with activities such as walking, lifting weights, ensure good bone health.

In addition, these women should also avoid smoking, excessive drinking, taking excessive thyroid replacement medications, and/or medications such as steroids or proton pump inhibitors. If anxiety issues are indeed found on screening, they should be addressed and professionally handled – with various techniques including mindfulness, cognitive therapy, self-calming strategies, yoga, etc.

 

Urgent Orthopedic Injuries

While some orthopedic injuries can heal on their own, others require urgent treatment. Such injuries and problems include:

  • Cuts and lacerations
  • Fractures
  • Ligament tears
  • Painful, swollen joints
  • Pediatric injuries
  • Sports injuries
  • Sprains, strains, and discolorations

Orthopedic Injuries that should be urgently treated by an orthopedic doctor or surgeon –

Any injury or condition that can prove serious or life-threatening should be treated at a hospital ER, such as –

  • arm or leg is severely fractured and/or out of alignment
  • bone is fractured and exposed through the skin
  • significant blood loss has occurred
  • other injuries from falls or accidents are present
  • severely injured children

Children who require urgent orthopedic care include:

  • children with a fractured bone, are experiencing pain and/or are irritable, despite treatment and medication. Any pain, swelling, redness, tenderness at a site or injury that has been treated may also require urgent medical attention.
  • children who have no obvious symptoms of an injury but is crying, restless, feverish, and unable to walk. This could indicate a serious hip joint infection.
  • children with large, deep cuts or wounds
  • children with positional deformities of the limbs

To learn more about orthopedic injuries and treatments, call the top orthopedic surgeon in Gilbert, AZ, call OSPI Arizona at 480-899-4333. OSPI’s Board Certified orthopedic surgeons offer complete care and treatment for individuals in all stages of life, participating in all levels of activity. This includes orthopedic, physical therapy, chiropractic, medical weight loss, hormone replacement, performance training, pain management, podiatry, regenerative medicine, stem cell therapy and family practice.

Do Vestibular Disorders Go Away With Manual Lymphatic Drainage?

The vestibular sensory organs in our inner ear, the cochlea, and the semicircular canals are responsible for our balance and proprioception/position. When these organs are damaged with disease or injury, it can lead to dizziness, vertigo, balance problems, and other symptoms. These can be transient as people are able to recover after a few weeks of normal activity due to vestibular compensation. Conversely, the symptoms can be lasting, affecting a person’s ability to maintain posture and balance.

 

A person with a vestibular disorder may have difficulty in maintaining balance and may adopt an exaggerated hip sway, swivel the entire body while keeping the head still when turning to look at something, or always look down to avoid a confusing swirl of activity. Ironically, these mannerisms can worsen the vestibular symptoms and often cause headaches, muscle tension, and fatigue.
Meniere’s disease is the most common vestibular disorder this procedure is considered for

Endolymphatic sac decompression is a procedure that involves draining of the excessive endolymph from its sac in order to decompress it. It is sometimes indicated for Ménière’s disease or secondary endolymphatic hydrops to relieve endolymphatic pressure in the cochlea and vestibular system. Meniere’s disease is the most common vestibular disorder this procedure is considered for. It is characterized by vertigo, tinnitus, hearing loss, imbalance and a feeling of pressure deep inside the ear. While there are several treatment options for it, including betahistine, cyclizine, steroid injections, and gentamicin injections, but endolymphatic sac decompression is considered for refractory cases.

 

There are multiple ways to perform this procedure. One method involves removing the mastoid bone surrounding the endolymphatic sac and allowing the sac to decompress. Alternatively, a shunt may be placed into the endolymphatic sac so that the excess fluid can drain out into the mastoid cavity.

Endolymphatic sac decompression is performed as an outpatient procedure. During the procedure, an incision is made behind the ear and the mastoid bone is exposed. The bone is fragmented to reveal the endolymphatic sac and a hole is cut into the outer layer of the sac using a laser. A shunt is then inserted into the sac and the incision is closed. The procedure takes approximately 90 minutes and is performed under general anesthesia. If there are no adverse events, the patient is discharged an hour later. Most patients return to work the day after surgery. The patient’s hearing gradually improves in the ensuing few weeks and then returns to normal.

Endolymphatic sac decompression has proven to be an effective treatment for patients with Meniere’s disease with vertigo and light-to-moderate hearing loss. In a recent study published in JAMA, endolymphatic sac surgery provided an improvement in major spells of vertigo in 77% of patients at 24 months after surgery. Furthermore, revision surgery provided an improvement in 65% of cases, especially those with recurrent symptoms more than 24 months after their original procedure.

Symptoms of an ACL Injury

The ACL or Anterior Cruciate Ligament connects the bottom of the thigh bone or femur to the top of the shin bone or tibia. It is one of the four knee ligaments that keep the knee stable and prevent rotational stress. ACL is the weakest of these four ligaments and can get torn when subject to excessive stress.

ACL injuries are common among athletes and active individuals, especially during sports that involve sudden halts and changes in direction, such as basketball and soccer.

Symptoms of an ACL injury

  • “Popping” or a “clicking” sensation in the knee
  • Severe pain
  • Inability to continue activity
  • Swelling within a few hours
  • Loss of range of motion
  • Feeling of instability

Treatment for ACL Injury

To avoid more damage, such as meniscus tears and degenerative joint disease, reconstructive ACL surgery is done. Such surgery also provides stability and function in the knee. Your surgeon may use the repair tissue from your own hamstring (autograft) or from a cadaver (allograft).

Prevention of ACL Injuries

You can reduce the chances of an ACL injury with adequate warm up before activity, training drills to improve power and agility and by improving balance.

Sports medicine doctors now offer regenerative medicine options such as PRP therapy and stem cell treatments to treat conditions involving the shoulder, elbow, hip and knee.

To learn more about regenerative medicine treatments, such as PRP therapy, call the best orthopedic and knee replacement doctors in Gilbert, AZ, call OSPI Arizona at 480-899-4333. OSPI’s Board Certified orthopedic surgeons have extensive experience and expertise in sports medicine, general orthopedics and joint replacement surgery.

Grade I Hamstring Strain

Hamstrings are the three muscles at the back of the thigh. They traverse between the hip and the knee and are named semimembranosus, semitendinosus and biceps femoris. They are involved in bending the knee., tipping the pelvis back when you lean backwards, and twisting the knee when the knee is bent.

 

A hamstring injury ranges from a strain to a muscle tear.
There are three grades of hamstring injury:

  • Grade I: a mild muscle strain
  • Grade II: a partial muscle tear.
  • Grade III: a complete muscle tear or tear of an attachment.

 

Grade I injury may take a few days to heal but a grade III injury can take months. We’ll focus on grade I hamstring injury in this article.

The best way to avoid hamstring injury is to spend time working on your hamstring strength

Grade I Hamstring injuries are very common in sports, especially those that involve sprinting, suddenly stopping and changing direction, and jumping. These include football, rugby, baseball and track running. They typically happen at the end of the swing phase of running, just before the outstretched leg touches the ground, as it is at this point that the hamstring muscles have to suddenly contract to bend the knee.

 

There are multiple predisposing factors for hamstring injury, such as:

 

  • Weak hamstrings – if they are not toned up and strong enough to handle the stress, they are more likely to get injured.
  • Lack of warm-up before exertion – Hamstring muscles are less likely to be injured when they are warmed up through brief stretching/contracting exercises. Keeping the legs warm with suitable clothing while warming up also helps a lot.
  • Tiredness – if the muscle is fatigued, it is more likely to get injured. Having good fitness overall helps.
  • Previous hamstring injury – You are much more likely to have a hamstring injury if you have had a previous one.
  • Older age – you are more likely to have a hamstring injury as you get older.

 

Interestingly, being overweight is not thought to be a risk factor for a hamstring injury.

The best way to avoid hamstring injury is to spend time working on your hamstring strength. A highly trained sportsperson will tend to do this as part of their training but anybody looking to do any activities that involve these muscles is probe to grade I hamstring injury and needs to warm up as well.

There are various approaches to hamstring rehabilitation, with varying times of immobilization to the type of exercise. The goal of any hamstring rehabilitation (especially so in cases of sportspersons) is to return to the previous level of performance while attempting to minimize the rate of injury recurrence. It has been shown that Grade I (and even II) hamstring strains can be aggressively treated with brief immobilization followed by early initiation of running and isokinetic exercises. This is likely to lead to early recovery of function and a relatively low reinjury rate.

Microfracture of the Knee – Recovery & Outcomes

Microfracture is a simple but cost-effective procedure performed to treat smaller cartilage injuries. It is not used to address defects with damage to the underlying bone. It also cannot be used to treat widespread arthritis in a joint. But it is an excellent choice as an initial treatment of smaller articular cartilage injuries.

 

Recovery process

After the microfracture repair of the knee, the post-operative recovery period is fairly complication-free. After the procedure has been performed in the patella and the trochlear groove, there will likely be mild transient pain or “gritty” sensation. The pain resolves sooner but the gritty sensation typically resolves with a few weeks. Patients may notice “catching” as the ridge of the patella rides over this area during joint motion. This may be apparent during continuous passive motion machine (CPM). If it is also painful, it is best to limit weight bearing; it should resolve within 3 months. Any residual swelling and joint effusion disappears within 8 weeks after microfracture. Sometimes, there is a recurrent effusion between 6 to 8 weeks after surgery but it is usually painless and typically resolves within several weeks.

 

Rehabilitation

The rehabilitation process is vital to the long-term success and functional outcome of these patients. Postoperative rehabilitation programs for microfracture procedures vary greatly based on lesion size, depth, location, quality of tissue, patient age, BMI, general health, and surgical details. Thus, the appropriate rehabilitation program must be highly individualized to ensure successful outcomes. The goal of rehabilitation is to restore full function in the shortest time possible without overloading the healing articular cartilage. It is imperative to create a healing environment while avoiding deleterious forces that may overload the healing tissue.

The pain resolves sooner but the gritty sensation typically resolves with a few weeks

Paste grafting

In order for microfracture to work consistently, the healing tissue must be stimulated to form cartilage rapidly and durably. The progenitor/stem cells and bone paste can be added to a super microfracture of the lesion in a technique called Paste grafting. The healing process can be augmented by injections of growth factors and hyaluronic acid lubrication injections during the healing period.

 

Outcomes

The studies are showing mid-term and long-term success for microfracture in the knee. Multisite microfracture was seen to have poorer outcomes. This is likely because multiple cartilage injuries are indicative of a more advanced disease process. It has been found that patients younger than 45 years had significantly improved outcomes after microfracture as compared with those older than 45 years. Patient age and BMI have been found to be significant predictors of postoperative improvement after microfracture.

 

Overall, presence of a single cartilage lesion, lower BMI, or being a male has been found to result in greater functional improvement after microfracture. Moreover, larger defects (>3.6 sq.cm) and prior surgery were both independent predictors for future surgery after microfracture.

How can PRP Therapy Heal my Orthopedic Injury?

PRP or Platelet Rich Plasma is simply blood plasma, rich in platelets. Human blood consists of plasma, red blood cells, white blood cells, and platelets. The role of platelets is to aid blood clotting in the event of an injury. However, platelets also contain hundreds of granules of growth factors and cytokines that help in healing. Many growth factors contained in these granules aid building new connective tissue, creating new blood vessels, other calling other cells that help healing, and reducing inflammation.

PRP is created by centrifuging or spinning a sample of your own blood to get concentrated platelets (3-5 times that present in blood) in a small volume. This concentrated plasma or PRP is a powerful healing product with multiple growth factors and cytokines.

PRP has been used to help healing of various orthopedic injuries, especially –

  • chronic tendon injuries, for example, tennis elbow
  • acute soft tissue injuries, for example hamstring tears
  • arthritis
  • surgical augmentation

Benefits of PRP Therapy

3 biggest benefits of PRP therapy are –

  • PRP comes from your own body and uses your body’s own natural healing ability for healing and pain relief
  • PRP can be administered with an injection under ultrasound or fluoroscopic guidance
  • PRP has the potential to return you to activity in a short time without surgery. This is beneficial in terms of not only shortened recovery, but also in terms of avoiding the high costs of surgery and missed time off work.

To learn more about regenerative medicine treatments, such as PRP therapy in Gilbert, AZ, call OSPI Arizona at 480-899-4333. OSPI’s Board Certified orthopedic surgeons have extensive experience and expertise in sports medicine, general orthopedics and joint replacement surgery.

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