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JOHNS HOPKINS
SUMMER 2013
A JOURNAL OF JOHNS HOPKINS ORTHOPAEDIC AND SPINE SURGERY AT MEDSTAR GOOD SAMARITAN HOSPITAL
CERVICAL STENOSIS
Diagnosis and Treatment Options
LATERAL EPICONDYLITIS
Tennis Elbow
ARTHRITIS OF THE KNEE
Managing Pain and Restoring Function
SHOULDER DISLOCATION
TREATMENT ALTERNATIVES
Pearls and Pitfalls
1
Table of Contents
Letter to the Readers............................................................... 3
Johns Hopkins Orthopaedic and Spine Surgery at
MedStar Good Samaritan Hospital......................................... 3
Cervical Stenosis..................................................................... 4
Lateral Epicondylitis................................................................ 6
Meet Our Surgeons................................................................. 8
Arthritis of the Knee..............................................................11
Shoulder Dislocation Treatment Alternatives......................... 14
Volume 2 Issue 1 • 2013
Johns Hopkins Orthopaedic & Spine Surgery
at MedStar Good Samaritan Hospital
www.hopkinsorthogsh.com
2
443.444.4730
Letter to the Readers
Hello, and welcome to our summer edition of ATLAS. It is our
intent to use this journal as a vehicle for keeping you abreast
of various topics that are current within health care. We would
also like to keep you informed of events and activities within
our practice.
Today, we are seeing health care enter a new era with the advent
of the Affordable Care Act. This sweeping legislation, which
touches upon many areas, is scheduled to become effective in
2014. And, while we do not know fully the challenges that lie
waiting, we are beginning to see traces of the changes as the
industry prepares for its implementation.
Here at Johns Hopkins Orthopaedic and Spine Surgery at
MedStar Good Samaritan Hospital, we stand ready for those
coming changes and welcome their implicit dynamism. This,
after all, is one of medicine’s main characteristics, and it is this
evolutionary propulsion that urged on the efforts to reach the
depth of skills, knowledge and achievements existing in health
care today.
Since our founding nearly 40 years ago, our doctors have
pursued the optimal treatment and care for our patients. This
has involved not only direct patient care but also activities in
research, consultation and development of various surgical
instruments and implants. We are
committed and dedicated to our mission
of improving the quality of life for
our patients by utilizing state-of-theart procedures and techniques. Our
philosophy is a conservative regimen that
is predicated upon achieving long-term
superior clinical outcomes while utilizing
the least-invasive methods available.
With the acme of our focus directed solely
on patient care, we offer the following articles. We hope you
find them informative and relevant, as well as enjoyable reading.
Please do not hesitate to contact me — my personal e-mail
address is listed below — should you have any questions or if
you would like to obtain more information.
Mesfin A. Lemma, MD
Division Chief
Johns Hopkins Orthopaedic and Spine Surgery
at MedStar Good Samaritan Hospital
[email protected]
Johns Hopkins Orthopaedic and Spine Surgery at MedStar Good Samaritan Hospital
A Commitment to Improving Our Patients’ Quality of Life
Since its establishment in 1974 by
world-renowned surgeon Dr. David
S. Hungerford, the Johns Hopkins
practice at MedStar Good Samaritan
Hospital has enjoyed nearly 40 years
of excellence and leadership in the
field of orthopaedic surgery.
During the past 40 years, the group has
grown in size and has advanced patient
care in all subspecialties of orthopaedics,
including arthroscopic surgery, shoulder
reconstruction, foot and ankle surgery,
general orthopaedic surgery, joint
replacement, spine care and sports medicine.
Our board-certified surgeons are
experienced, skilled and subspecialty-
trained to care for adults of all ages with
musculoskeletal conditions caused by illness,
injury or everyday life. Utilizing state-of-theart diagnostic services and the latest nonsurgical and surgical methods, we strive to
maximize function and minimize discomfort
for our patients.
We partner with physical therapists,
physiatrists and other medical providers
to ensure that you are treated with a
comprehensive and multidisciplinary
approach for your condition with an emphasis
on exhausting non-operative measures first.
If, after a thorough evaluation, we
determine that you are a candidate for
surgical intervention, you will benefit
from advanced techniques ranging from
minimally invasive procedures to complex
reconstructive surgery using state-of-theart technologies, such as our new 3-D
intraoperative BrainLab imaging system for
advanced spine and hip surgery.
Selecting a specialist is an important
decision. From the moment you enter the
comfort of our offices until you are on the road
to recovery, your case is professionally handled
from start to finish, with a customized care
plan and guidance from your initial diagnosis
through all phases of your treatment.
Please call or visit us to learn more.
443.444.4730
www.hopkinsorthogsh.com
3
Stenosis
DIAGNOSIS AND TREATMENT OPTIONS
by Mesfin A. Lemma, MD
by Mesfin A. Lemma, MD
Background
The cervical spine refers to the upper portion
of the spinal column — the portion that
is within our neck. This portion of the
spinal column is made up of seven bones, or
vertebrae, along with their corresponding discs,
which act as shock absorbers. This column of
bone and disc has a tunnel that runs through
it, referred to as the spinal canal, in which the
spinal cord and nerve roots travel — think of
this as the spinal “highway.” Individual nerve
roots then branch off the spinal cord, “exit” the
spinal canal and travel down to make up the
nerves to the arms and hands.
The spinal cord functions to carry signals
from the brain into the arms, legs and body
and, at the same time, carries signals back
to the brain from the arms, legs and body.
The spinal nerve roots, in turn, control
individual muscles or are responsible for
feeling in certain parts of the arm or leg.
This unique anatomy allows the spine to
be flexible enough to allow us to turn the
head from side to side and up and down but,
at the same time, strong enough to protect
the delicate spinal cord and spinal nerves
that travel through it.
What Is Cervical Stenosis?
In certain conditions, the spinal canal
narrows, thereby exerting pressure on the
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spinal cord or exiting nerve roots. This is
referred to as cervical stenosis. While some
patients are born with this narrowing,
most cases of cervical stenosis are due to
degenerative changes in the spine that are
the result of wear and tear that typically
progresses with age. Some patients with
cervical stenosis have a history of injury or
trauma to the neck; however, this trauma
may have occurred many months or even
years before the onset of stenosis symptoms.
Other causes, such as tumor, infection or
calcification of the ligaments, are rare.
Sometimes, a portion of a disc may
herniate (rupture) and put pressure on the
nerves. Furthermore, as the degenerative
changes progress, the discs collapse and
decrease in height, the ligaments of the spine
thicken, and bone spurs (osteophytes) may
form. These changes all contribute to the
narrowing of the spinal column and may
lead to increased pressure on the spinal cord
or the exiting nerves.
In instances where the spinal canal, or
“highway,” is narrowed, cervical myelopathy
may result. This refers to a loss of function
in the upper and lower extremities secondary
to compression of the spinal cord within
the neck. This is a more serious condition.
When the “exits” are involved, this spares
the spinal cord and only affects the
individual nerve roots traveling down a
specific region of the arm. This often results
in cervical radiculopathy, or pain, numbness,
tingling or loss of function in a specific
region within the arms.
How Is It Diagnosed?
Cervical stenosis is usually suspected based on
the patient’s history and physical examination.
X-rays of the neck may show bone spurs,
misaligned bones, evidence of injury, or
narrowing of the space between vertebral
bodies and resultant nerve impingement. A
more specialized type of imaging, magnetic
resonance imaging (MRI), may also be
obtained. The MRI will provide a threedimensional view of the spine to demonstrate
the condition of the intervertebral discs, the
ligaments, and the spinal cord and nerves. The
MRI is the most common way to diagnose
the presence of nerve compression. Other
types of imaging studies, such as CT scans
and myelograms (a test that involves injecting
liquid contrast dye into the spinal column
to show where the spinal cord pressure is
occurring), may also be used in certain cases to
help make the diagnosis.
Some patients undergo electrical
testing of the nerves and spinal cord.
Electromyograms (EMGs) and nerveconduction studies can assist in helping
distinguish cervical radiculopathy from
other nerve problems in the arm and
forearm, such as carpal tunnel syndrome.1
What Are the Symptoms?
When cervical stenosis becomes
symptomatic and affects the exiting nerve
roots, it most often causes pain or numbness
in the arms and/or hands, referred to as
radiculopathy. Neck pain often accompanies
cervical stenosis as the joints in the spine
become arthritic and stiff. The symptoms
are usually localized to only one side of
the body with the specific location of the
symptoms determined by the specific nerve
being compressed.
As the stenosis worsens, it may cause
compression of the spinal cord itself —
referred to as cervical myelopathy. This can
cause a wide variety of symptoms, such as
numbness and weakness in the arms and/or
legs, a sense of clumsiness or loss of manual
dexterity in the hands (such as difficulty
buttoning shirts or worsening handwriting),
or loss of balance. Gait may become
noticeably wobbly. In extreme cases, patients
may develop more profound weakness and
numbness in their arms and legs and, rarely,
changes in bowel or bladder control. If any
of these symptoms are present, you should
let your doctor know immediately.
Most patients with myelopathy will
experience a progression of symptoms. The
timeframe of this progression, the degree of
progression and the speed of progression are
not known. It is estimated that 75 percent
of patients will experience what is known
as stepwise deterioration in their function,
or stable periods in between periods of
deterioration. Approximately 20 percent
of patients will experience slow, steady
deterioration, and another 5 percent will
experience deterioration at a rapid pace.1
What Are the
Treatment Options?
Nonoperative Treatment
In most cases, cervical stenosis can be
successfully treated with nonsurgical
techniques such as pain and anti-inflammatory
medications. Some patients may need to limit
their activities for a time or wear a cervical
collar or neck brace temporarily, depending
on the extent of nerve involvement. However,
most patients only require rest. Physicaltherapy exercises may be prescribed to help
strengthen and stabilize the patient’s neck,
build endurance and increase flexibility.2
Sometimes, acute flare-ups may be treated
with a brief course of oral steroids and/or pain
medications. Injections using local anesthetic
agents or steroids may be performed in certain
cases to help reduce the inflammation and
relieve pain associated with the irritated nerve.
Surgical Treatment
In those patients for whom nonoperative
measures prove unsuccessful, surgical
measures may be considered. Several factors
will be considered by a surgeon in choosing
the type of surgery best for a patient,
including the exact location of any spinalcord or nerve-branch compression, the
number of levels where compression exists,
the patient’s overall cervical spine alignment
and the patient’s overall condition.1
Smaller procedures might involve only
removing the bone spur or a portion of
the herniated disc that is causing the
compression, usually performed via a
minimally invasive approach. Other surgical
treatment options include fusions with
placement of titanium implants or artificial
disc replacement, which is an effective
way of relieving nerve pain while avoiding
a fusion procedure. Surgery on the neck
may be performed from the front, back or
both, depending on the pathology. The
appropriate treatment protocol, including
which, if any, surgical procedures are
warranted, is a decision that is made by the
patient and surgeon and is based on the
individual circumstances of each case.
References
1. Rao, Raj, MD. “Cervical Stenosis, Myelopathy
and Radiculopathy.” North American Spine Society.
www.knowyourback.org/pages/spinalconditions/
degenerativeconditions/cstenosis_myelopathy_
radiculopathy.aspx.
SPINE SURGERY
Mesfin A. Lemma, MD
Robert M. Peroutka, MD
Conditions Treated:
• Cervical, thoracic and lumbar stenosis
• Cervical, thoracic and lumbar
disc herniations
• Myelopathy
• Spine tumors
• Spine trauma
• Vertebral compression fractures
• Rheumatoid involvement of the spine
• Adult scoliosis
• Adult kyphosis
• Osteoporotic spine fractures
• Multiple myeloma involvement of
the spine
Please visit www.hopkinsorthogsh.com
to view our state-of-the-art 3-D animated
video library, which contains over 200
orthopaedic topics.
2. B, Pal. “Cervical Spinal Stenosis.” www.
cervicalrelief.com/cervical-spinal-stenosis.
Dr. Lemma is a fellowship-trained, board-certified
orthopaedic surgeon with Johns Hopkins Orthopaedics
at MedStar Good Samaritan Hospital. He is the
division chief of Johns Hopkins Orthopaedic and
Spine Surgery at MedStar Good Samaritan Hospital,
co-director of spine surgery, and assistant residency
director and assistant professor in the Department of
Orthopaedic Surgery at the Johns Hopkins School of
Medicine. Dr. Lemma specializes in cervical spine
trauma, minimally invasive spine surgery, spinal
disorders, and spine and spinal deformities.
For more information, please visit:
• www.hopkinsorthogsh.com
© 2013 The Johns Hopkins University, The Johns
Hopkins Hospital, and Johns Hopkins Health System,
all rights reserved.
5
Lateral Epicondylitis –
Tennis Elbow
by Jonathon Rigaud, BSc, and Bashir A. Zikria, MD
Introduction
Lateral epicondylitis, also referred to as
tennis elbow or epitrochlear bursitis, is a
common injury for people who play tennis or
any sport involving a racquet. Additionally,
any activity that involves repetitive twisting
of the wrist can cause tennis elbow. Workers
with jobs involving this motion are more
inclined to develop this condition: cooks,
painters, plumbers and butchers. According
to the National Institute of Health’s Medical
Dictionary: “Tennis elbow refers to soreness
or pain on the outside (lateral side) of the
upper arm near the elbow.” The forearm
tendons, often called extensors, attach your
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forearm to the outside of your
elbow. More specifically, the
extensor carpi radialis brevis
(ECRB) muscle plays an integral
part in stabilization of the wrist
when the elbow is straight. The
accumulation of microscopic tears due to
overuse and weakening of the ECRB can
lead to irritation, pain, and discomfort
causing lateral epicondylitis.
History
Lateral epicondylitis typically occurs in
adults 40 to 50 years of age. Patients often
report onset of this injury as a result of
a history of overuse without any specific
trauma being done to the elbow. The
clinical entity was first described by Runge
in 1873. Most of the reported cases have
been nonathletic, middle-aged females
conducting normal household jobs. The
majority of patients with lateral epicondylitis
often pursue nonoperative management,
like steroid injections. This is important
to note because surgical candidates are
usually patients with steroid deposition and
chronic pain in the ECRB. The patients
who pursue nonsurgical operations often
lack inflammatory response due to steroid
use. Additionally, in these cases, this may
result from lack of tendon healing, causing
requirement of surgery. Most histological
studies report a degeneration process in the
cells and tissue surrounding the elbow.
Symptoms
Patients with lateral epicondylitis often
report gradual worsening of elbow pain,
pain outside the elbow resulting from
twisting or grasping, or weak grip strength.
In most cases, the pain begins as mild and
gradually worsens as weeks go by. Delayed
symptoms can result from microscopic
tears in the tendons. The dominant arm
is predominantly affected by this injury;
however, it is not limited to just that arm.
Symptoms are often worsened by activities
like shaking hands, turning a wrench,
holding a racket, or anything involving a
twisting or grasping motion.
Diagnosis
Diagnosis for tennis elbow cannot be
determined using X-rays or blood tests
because of the microscopic tears. Physical
examinations often reveal tennis elbow due
to the description of pain from the patient.
In order for the correct diagnosis to be
made, patients should see their doctor, since
there are numerous other conditions that
can cause pain around the elbow. Testing
of muscular strength can reveal weakness
in the wrist extensors, as well as testing full
elbow extension. Mills’ test and Maudsley’s
test are often helpful in diagnosing tennis
elbow. Mills’ test is conducted by requiring
the patient to demonstrate complete wrist
and finger flexion. Pain at the elbow due to
resistance can lead to lateral epicondylitis.
Maudsley’s test requires the patient to resist
extension of the middle finger when the
elbow is fully extended and the forearm
is pronated. If pain develops, diagnosis
of tennis elbow can be made. Lateral
epicondylitis is classified according to the
Nirschl Classification. The patient can
progress from one stage to the next:
•Stage 1 – Inflammatory changes that
are reversible
•Stage 2 – Nonreversible pathologic changes
to origin of the extensor carpi radialis
brevis (ECRB) muscle
•Stage 3 – Rupture of extensor carpi radialis
brevis muscle origin
•Stage 4 – Secondary changes such as
fibrosis or calcification
Treatment
Nonoperative
The mainstay of treatment for lateral
epicondylitis is nonoperative management.
The treatment begins with activity
modification (cessation of the offending
activity), rest, bracing (counterforce brace),
and nonsteroidal anti-inflammatories.
Along with the above treatment, it is very
important to include a physical-therapy
program when the patient is pain-free.
The therapy program should emphasize
stretching and gradual strengthening in
a progressive way. Cortisone can be used
along the way as an acute anti-inflammatory
agent. However, it is important to limit
cortisone injections. Recently, platelet-rich
plasma (PRP) injections have shown some
promise in treatment of epicondylitis.
Regaining full strength and flexibility is
critical before returning to your previous
level of sports activity. Generally, 80 to
90 percent success has been reported for
nonoperative treatment.
Operative
Surgical therapy should be reserved
for patients only after they have failed
nonoperative management for at least six
to 12 months. There are myriad surgical
procedures for lateral epicondylitis, both
minimally invasive (arthroscopic) and
open procedures. The procedures all
essentially debride degenerative tissue
of the ECRB tendon and decorticate
the bone. Both open and arthroscopic
procedures have very good success. The
advantage of the arthroscopic approach has
been shown to allow earlier rehabilitation
and resumption of activities. Our approach
is an arthroscopic approach and has shown
excellent and reproducible results.
References
1. Geoffrey, Pierre, Mark J. Yaffe, and Ivan Rohan.
“Orthopedics Article.” Diagnosing and treatment of
epicondylitis. N.p., n.d. Web. 7 Oct 2012.
SPORTS SURGERY
Bashir Zikria, MD, MSc
Steve A. Petersen, MD
Conditions Treated:
• Shoulder instability
• Muscle/tendon injuries of
the shoulder
• Failed shoulder surgeries
• Acromioclavicular joint conditions
• Sports injuries of the shoulder
• Biceps tendon/glenoid
labral injuries
• Baseball and throwing injuries
• Multiligament knee injuries
Please visit www.hopkinsorthogsh.com
to view our state-of-the-art 3-D
animated video library, which contains
over 200 orthopaedic topics.
2. Regan, William, Lester E. Wold, and Ralph
Coonrad. “Microscopic histopatholog y of
director of Johns Hopkins Sports Medicine at MedStar
chronic refractorty lateral epicondylitis.” The
Good Samaritan Hospital. Dr. Zikria is also an
American Journal of Sports Medicine. N.p.,
assistant professor in the Department of Orthopaedic
n.d. Web. 7 Oct 2012. http://ajs.sagepub.com/
Surgery at the Johns Hopkins School of Medicine, as
content/20/6/746.full.pdf.
well as a team physician for the Baltimore Orioles.
3. “Lateral Epicondylitis Presentation.” Medscape.
Medscape, 10 03 2012. Web. 7 Oct 2012. http://
For more information, please visit:
emedicine.medscape.com/article/96969-clinical.
• www.hopkinsorthogsh.com
Dr. Zikria is a fellowship-trained, board-certified
© 2013 The Johns Hopkins University, The Johns
orthopaedic surgeon with Johns Hopkins Orthopaedics
Hopkins Hospital, and Johns Hopkins Health System,
at MedStar Good Samaritan Hospital. He is the
all rights reserved.
Tips for Preventing Tennis Elbow
• Perform warm-up and cool-down exercises before and after tennis play that includes
stretching the muscles in the arm.
• Use appropriately sized tennis equipment. Racquet handles and heads that are too
big or too small or strings that are too tight or too loose can put more stress on
the elbow.
• Evaluate poor tennis technique that may be contributing to the problem. Learn new
ways to play that avoid repeated stress on the joints.
7
Johns Hopkins Orthopaedic & Spine Surgery
at MedStar Good Samaritan Hospital
Our Locations
Johns Hopkins Orthopaedic & Spine Surgery
at MedStar Good Samaritan Hospital
5601 Loch Raven Boulevard, Smyth Building
Baltimore, MD 21239
Johns Hopkins expertise in a private,
community hospital setting
SHOULDER
SPINE
HIP & KNEE
SPORTS
FOOT AND
ANKLE
GENERAL
ORTHOPAEDICS
Johns Hopkins at Green Spring Station
10753 Falls Road, Pavilion II
Lutherville, MD 21093
Johns Hopkins at White Marsh
4924 Campbell Boulevard – Suite 200
Whitemarsh, MD 21236
www.hopkinsorthogsh.com
443.444.4730
York Green
1300 York Road
Building C – Suite 100
Lutherville, MD 21093
Johns Hopkins Orthopaedic & Spine Surgery
at MedStar Good Samaritan Hospital
www.hopkinsorthogsh.com
443.444.4730
MEET OUR SURGEONS
David S. Hungerford, MD
Mesfin A. Lemma, MD
Professor, Orthopaedic Surgery
Former Chief, Arthritis Division
Founder, Johns Hopkins Orthopaedics at
MedStar Good Samaritan Hospital
Division Chief, Johns Hopkins Orthopaedics at
MedStar Good Samaritan Hospital
Assistant Professor, Orthopaedic Surgery
Co-Director, Spine Surgery at MedStar
Good Samaritan Hospital
Becker’s 100 Best Spine Surgeons in the U.S.
Steve A. Petersen, MD
Daniel J. Valaik, MD
Associate Professor, Orthopaedic Surgery
Director, Shoulder Surgery at MedStar
Good Samaritan Hospital
Co-Director, Johns Hopkins Shoulder
Fellowship Program
Best Doctors in America, 2002-present
Assistant Professor, Orthopaedic Surgery
Hip & Knee Joint Replacement
Former Chief of Orthopaedics, Bethesda Naval Medical Center
Johns Hopkins Orthopaedic & Spine Surgery
at MedStar Good Samaritan Hospital
www.hopkinsorthogsh.com
443.444.4730
Steven A. Kulik Jr., MD
Darioush Nasseri, MD
Robert M. Peroutka, MD
Clinical Associate, Orthopaedic Surgery
Director, Foot & Ankle Surgery
Assistant Professor, Orthopaedic Surgery
Arthroscopic Surgery and Hip & Knee
Joint Replacement
Assistant Professor, Orthopaedic Surgery
Director, Joint Experience at MedStar Good
Samaritan Hospital
Director, Adult Reconstructive
Surgery Fellowship
WHY SHOULD YOU CHOOSE JOHNS HOPKINS
ORTHOPAEDIC AND SPINE SURGERY AT
MEDSTAR GOOD SAMARITAN HOSPITAL?
Expert, Compassionate Care
PATIENT SERVICE — Serving our patients is a top priority at our practice. We strive
to ensure your experience with us is the best it can be.
EXPERTISE — Our surgeons are full-time faculty members at The Johns Hopkins
University and School of Medicine and are regionally and nationally recognized
leaders in their fields.
NATIONAL CENTER OF EXCELLENCE — We have been recognized by U.S. News
& World Report as a Center of Excellence for Orthopaedic Surgery.
Bashir Zikria, MD, MSc
Assistant Professor, Orthopaedic Surgery
Director, Johns Hopkins Sports Medicine at
MedStar Good Samaritan Hospital
Sports Medicine
Team Physician, Baltimore Orioles
21ST-CENTURY TECHNOLOGY — Our surgeons utilize the latest in minimally
invasive surgical techniques, which means more precision, smaller incisions and
quicker recovery times for our patients.
RESEARCH AND TRAINING — We are actively involved in the training of residents
and fellows and help advance the field of surgery through research and education.
You have a choice in your orthopaedic care. And when you want the best, Johns
Hopkins Orthopaedic and Spine Surgery at MedStar Good Samaritan Hospital is the
choice for you.
Call us at 443.444.4730 to schedule an appointment, or visit us online at
www.hopkinsorthogsh.com to learn more.
10
Arthritis
of the Knee
MANAGING PAIN AND RESTORING FUNCTION
by Alexandria Lopez
OA develops when cartilage, a type of connective tissue that
allows bones to glide rather than rub against each other, wears
away. The thinning cartilage causes the bones that make up the
joint to scrape together, creating local inflammation and pain.
Eventually, the cartilage completely wears away, leaving exposed
bone. This increases pain and decreases the joint’s range of
motion, leading to the stiffness often associated with arthritis.
As the condition advances, patients have increased difficulty
performing their daily routines.
Though OA of the knee often develops over decades of regular
wear and tear on the joint, some patients are predisposed to the
condition. “Most of our patients with severe arthritis are between
their 60s and 80s, but there are some outliers,” said Robert M.
Peroutka, MD, an orthopaedic surgeon with Johns Hopkins
University. Dr. Peroutka noted that a patient’s genetics might
also play a significant role in the development of OA, as well as
previous trauma or infection of the knee joint.
Imagine waking up in the middle of the night with
an aching knee. As you listen to the rain falling on
your bedroom roof, your knee joint throbs, making
it nearly impossible to go back to sleep. You move
to get out of bed to find a book to read, but your
knee is stiff and painful to bend. Another good
night’s sleep is lost to arthritic pain.
Osteoarthritis: A Common Condition
One of the most common ailments to afflict Americans, arthritis — or
inflammation of the joints — touches the lives of millions of Americans
each year. Osteoarthritis, commonly known as OA, is the most prevalent
form of knee arthritis, although rheumatoid arthritis can also attack the
knee joints. According to a 2006 article in The Journal of Rheumatology,
symptomatic knee osteoarthritis affects 4.3 million older U.S. adults, or
more than one in 10 individuals.
The First Line of Defense:
Nonoperative OA Treatments
Once a patient is diagnosed with OA, treatment generally begins
with over-the-counter (OTC) medications. “The treatment
plan is to always start with the most conservative measures,”
Dr. Peroutka remarked. OTC treatments recommended for a
typical patient may include acetaminophen, non-steroidal antiinflammatory drugs (NSAIDs) and topical creams, ointments or
pain patches. These medications are indicated to relieve pain and
swelling and are often helpful for treating patients in the early
stages of OA.
Some patients also choose to take dietary supplements such as
glucosamine and chondroitin as a preventive measure, though
their level of effectiveness is uncertain. “Dietary supplements
may help maintain the quality of the cartilage, but it doesn’t stop
the progression of the arthritis,” Dr. Peroutka warned. If OTC
medications have no impact on a patient’s symptoms, the next
line of defense is prescription medicines.
11
Though it is critical for OA patients to engage in physical activity,
it is not uncommon for high-impact activities to be restricted.
“Patients with arthritis should modify their activity,” Dr. Peroutka
explained, noting that low-impact forms of exercise such as bicycling
and swimming allow patients to reap the health benefits of activity,
such as maintained motion and strength in the knees, without
placing undue stress on the joints.
Patients may also use braces or walking aids to alleviate some of
the stress on the arthritic joint. According to Dr. Peroutka, braces
may provide compression to reduce swelling and create support,
while also keeping the knee warm, which may help relieve pain
and stiffness in the joint. Canes, crutches and walkers help patients
decrease stress on the affected joint and maintain their mobility.
Some patients who find all classes of medication to be
ineffective may turn to injection therapy to ease their symptoms.
Cortisone injections can help decrease joint inflammation, while
viscosupplementation injections may reduce OA pain and improve
motion. However, as Dr. Peroutka noted, “No treatment has
been found to stop the progression of arthritis. The pain can be
decreased and the need for surgery delayed by several treatment
regimens. Viscosupplementation helps a lot of patients to delay
surgery, but it does not stop the progression of arthritis. The last
line of treatment is surgery.”
Restoring and Replacing the Joint:
Operative OA Treatments
Several surgical procedures are available for patients with OA of the
knee, including arthroscopy, high-tibial osteotomy, partial knee
replacement and total knee replacement. Before selecting a particular
course of treatment, physicians consider factors such as the degree of
arthritis, the alignment of the knee, a patient’s age, weight, medical
condition, lifestyle and response to other methods of treatment.
Complicating factors may include bad deformities of the knee, such as
a patient who is knock-kneed or bowlegged. “Mild knee deformities
are often present in patients undergoing knee replacement. Severe
deformities can make knee replacement more difficult and more
technically demanding,” Dr. Peroutka said. Comorbidities, such as
diabetes, may also lead to a higher risk for infections or difficulties
healing from the operation. “It’s not just focusing on the knee,” Dr.
Peroutka explained. “We look at the whole patient.”
Knee arthroscopy is both the least involved and the least common
surgical procedure used to treat OA of the knee. An outpatient
procedure, it uses small incisions to relieve “locking” and focal pain
within the knee that may be related to torn cartilage. However, if the
patient has significant arthritis, then the procedure’s benefit is often
temporary or nonexistent; arthroscopy may even aggravate the patient’s
existing symptoms, rather than relieving them.
RISK FACTORS FOR OA
Though there is no known way to
completely prevent arthritis, it is important
to know your risk factors. While the cause
of osteoarthritis is unknown, the Johns
Hopkins Arthritis Center suggests that the
following characteristics may predispose
an individual to developing OA:
•Aging
•Female gender
•Being overweight or obese
•Injury to or overuse of the joint
Age presently appears to be the strongest
risk factor for developing OA in any joint.
The rate of OA increases greatly among
men after they reach age 50 and among
women after they turn 40 years old.
However, there is a wide range in terms of
age among OA patients. “There are some
young patients that develop it early and
some patients that develop it very late in
life,” Dr. Peroutka noted.
12
Being female also appears to be a strong
correlation factor for osteoarthritis of
the hand. Women are also more likely to
report OA of the knee and pain in affected
joints than their male counterparts.
However, men are more likely to suffer
from OA of the hip.
Obesity is also a (reversible) risk
factor for developing OA of the knee.
“Decreasing weight can help decrease the
progression of arthritis,” Dr. Peroutka
explained. Though obesity has been
associated with OA of the knee and hip,
it is unclear whether body mass has any
affect on OA of the hand.
Joint injury or overuse may also
contribute to the onset of OA. While this
means that individuals who have physically
taxing occupations are at higher risk, highimpact activity of any kind may possibly
contribute to OA as well. According to
the Johns Hopkins Arthritis Center,
“While early studies in joggers failed to
find a higher prevalence of OA of the
knee in joggers compared to non-joggers,
a recent study of the Framingham data
base in elderly adults provided the first
longitudinal association between high
level of physical activity and incident
knee OA.” Low-impact activities such
as walking, bicycling, swimming and
skating do not appear to have a similar
correlation and, in fact, may be helpful
in decreasing the incidence of OA by
lowering body weight.
Though each of these factors plays an
important role in determining a patient’s
likelihood of developing OA, arthritis
is affected by a wide variety of variables.
Taking charge of factors within your
control may decrease your chance of
developing this degenerative disease.
High-tibial osteotomy can be beneficial for young, active patients
with arthritis in a single area of the knee, Dr. Peroutka explained. In
this procedure, the surgeon cuts the tibia and realigns the bone in the
knee in order to redistribute the weight away from the arthritic area
of the knee. Though the patient gets to keep his or her original joint,
this procedure is generally done as a means of delaying a future joint
replacement. The recovery time may be more extensive compared to
total knee replacement, and, according to Dr. Peroutka, patients may
still experience some pain because the arthritic joint remains.
When a physician decides if a patient needs a partial or total knee
replacement, several factors come into play, but the most important
factor is the location of the arthritis. Unicondylar, or partial, knee
replacement is recommended for patients who have arthritis in only
one side of the knee. According to Dr. Peroutka, the ideal candidate
for this surgery has intact ligaments, good stability of the knee and an
average weight. This surgery has a shorter recovery period than a total
knee replacement, but patients need to be aware that they may require
a total knee replacement in the future. Dr. Peroutka explained that,
while converting a partial knee replacement to a total knee replacement
is possible, it may be more difficult than undergoing a total knee
replacement without prior replacement surgery.
Total knee replacement is the most common surgical treatment for
OA of the knee. “It’s the most effective treatment, and, in most cases,
as patients go through the options of nonoperative treatment, the
arthritis progresses to the point where the entire joint is involved,” Dr.
Peroutka noted. “Most patients have widespread arthritis after years
of nonoperative treatment that can only be treated successfully with a
total knee arthroplasty.” After removing all of the patient’s damaged
cartilage and bone, the physician inserts a metal and plastic prosthesis
that resurfaces the knee joint. According to Dr. Peroutka, after
undergoing a total knee replacement, patients should have substantial
pain relief and be able to return to normal activities, with the exception
of high-impact activity. However, the surgery and rehabilitation are
more extensive for this procedure.
Though arthritis cannot be prevented, it’s important to take good
care of your joints today in order to avoid problems tomorrow. Dr.
Peroutka suggested that patients with OA avoid activities that place
undue stress on the knee and recommended that overweight patients
lose weight. However, he recognizes the importance of maintaining a
high quality of life. “It’s always a balancing act to manage the arthritic
pain and deal with it in each individual patient’s case,” he remarked.
“We can help patients have the quality of life they want while
managing their arthritis.”
For more information, please visit:
• http://www.hopkins-arthritis.org/patient-corner/disease-management/qol.html
• http://www.hopkinsortho.org/knee_arthroscopy.html
• http://www.arthritis.org/osteoarthritis-educate.php
© 2013 The Johns Hopkins University, The Johns Hopkins Hospital, and Johns
Hopkins Health System, all rights reserved.
ADULT RECONSTRUCTION
(HIP/KNEE)
Robert M. Peroutka, MD
Daniel J. Valaik, MD
Darioush Nasseri, MD
Hip Conditions
• Arthritis of the hip
• Avascular necrosis (AVN) of the hip
• Femoral-acetabular impingement (FAI)
• Hip bursitis
• Hip dislocations
• Hip fractures
• Femoral fractures
• Inflammatory arthritis of the hip
• Labral tears of the hip
• Muscle strain injuries of the hip
• Snapping hip syndrome
Knee Conditions
• Arthritis of the knee
• Avascular necrosis (AVN) of the knee
• Kneecap (prepatellar) bursitis
• Meniscus tears
• Osgood-Schlatter disease
• Osteochondritis dissecans of the knee
• Patellar tendonitis (jumper’s knee)
• Patellar tracking disorder
• Patellofemoral pain syndrome (runner’s knee)
• Septic arthritis of the knee
• Patella tendon rupture
• Quadriceps tendon rupture
• Fractures of the lower leg
Robert M. Peroutka, MD, serves as an assistant professor on the orthopaedic faculty
of Johns Hopkins University, as well as a team physician for the Baltimore Orioles.
Dr. Peroutka’s areas of interest include the hip, knee, total joint arthroplasty, adult
cervical spine and adult lumbar spine.
Please visit www.hopkinsorthogsh.com to view our state-ofthe-art 3-D animated video library, which contains over 200
orthopaedic topics.
13
Shoulder Dislocation
Treatment Alternatives
PEARLS AND PITFALLS
by Steve Petersen, MD
Is it always best to perform surgery for shoulder instability
arthroscopically? Not necessarily. Arthroscopic surgery is a
technique, not a principle, and the surgical treatment for shoulder
instability is dictated by several variables to include the correct
indications and the surgeon’s experience.
When we speak of shoulder dislocation, we are directing our
discussion to anterior shoulder dislocation. The most
common dislocation of any joint in the body, it represents
95 percent of dislocations involving the shoulder, with 4 percent
of shoulder dislocations being posterior and 1 percent inferior.
Shoulder dislocations are typically caused by an injury. There
14
are cases of a partial dislocation (subluxation) that may not be
related to a trauma, often associated with the repeated use of
the shoulder in a person with very lax tissues. For the purpose
of this article, we are talking about traumatic anterior shoulder
instability, either dislocation or subluxation. Furthermore, an
“apples-to-apples” comparison of open surgery versus arthroscopic
surgery relates to current repairs.
The pathology of injury to the shoulder that results in
dislocation is usually the result of a detachment of the capsule
from its glenoid (shoulder socket) attachment. The specialized
capsular attachment to the glenoid is called the labrum; therefore,
it is a labral avulsion. Associated with this injury is a stretching
of the anterior capsule. The glenoid rim can fracture as a variance
of the injury, and, about 85 percent of the time, the humeral head
(ball of the shoulder joint) will have an impression fracture of
varying sizes. This is called Hill-Sachs lesion. The significance
of these injuries relates to the treatment options and the surgical
indications for treating the injury.
A dislocated shoulder first has to be reduced (placed back in the
socket). This can occur in the emergency room (ER) by various
techniques and almost always is accomplished without going to
the operating room. It can be done under conscious sedation by
an ER physician or an orthopaedic surgeon. The question is what
to do next.
Shoulder dislocations in patients older than 40 often differ
from younger patients because they involve tearing of the rotator
cuff. This article will focus on the younger patient with a
capsular-labral injury as described above. The surgical indication
for treating a shoulder dislocation is persistent, symptomatic
instability. The diagnosis has to be well established by an exam
that reproduces the patient’s instability with imaging studies that
support the injuries seen with a dislocation. There must also be a
willingness from the patient to participate in rehabilitation.
The principles of surgical treatment are to repair the injured
tissues and restore stability with a repair that’s reproducible, has
predictable outcomes and minimizes complications. Surgery can
be accomplished with open or arthroscopic repairs. The standard
indications for an open repair are multiple recurrences with poor
tissue quality, a glenoid rim fracture or a large Hill-Sachs lesion,
an injury where the capsule tears off from the humerus rather
than the glenoid (HAGL lesion), or injury in a contact athlete.
The ideal indications for an arthroscopic technique are a
traumatic dislocation with a glenoid-labral avulsion, minimal
capsular laxity, few recurrences, noncollision activities, no bony
injury, quality tissues and a nondominant shoulder. Relative
contraindications are poor tissue quality, a glenoid fracture or a
large Hill-Sachs lesion, contact athletes and age less than 20 years.
The literature reports a redislocation rate of 3 percent for
the open technique and 8 to 13 percent for the arthroscopic
technique. Recently, results have been published by experienced
Symptoms of Shoulder Dislocation
• Pain in the upper arm and shoulder, which is usually worse
during movement
• Swelling
• Numbness and weakness
• Bruising
• Deformity of the shoulder (in a forward dislocation)
arthroscopic surgeons who have had success that is comparable
to the open technique when compared in well-controlled studies.
However, the rate of dislocation in collision sports remains
higher in arthroscopic repairs. Advantages of arthroscopic repair
over an open technique include avoiding a surgical exposure
through the subscapularis tendon, improved range of motion,
rapid initial recovery and less postoperative pain. The pitfalls of
arthroscopic repair include a steep learning curve with complex
instrumentation and
an opportunity for
technical errors. The
SHOULDER SURGERY
primary advantage
Steve A. Petersen, MD
of an open repair
Bashir Zikria, MD, MSc
is that its outcomes
are predictable and
Conditions Treated:
remain the “gold
• Shoulder instability
standard.” It’s also
• Failed shoulder
utilitarian, and there
• Shoulder fractures
isn’t a situation that it
• Biceps tendon/glenoid labral injuries
can’t handle. Pitfalls
• Sports injuries of the shoulder
include surgery to
• Shoulder arthritis
the subscapularis
• Rotator cuff disorders
and a possibility of
• Acromioclavicular joint conditions
restricted motion.
In summary, we
need to identify and
Please visit www.hopkinsorthogsh.com
treat the pathology
to view our state-of-the-art 3-D
with careful attention
animated video library, which contains
to patient selection.
over 200 orthopaedic topics.
The surgical technique
needs to be what
works best in the
surgeon’s hands
for the appropriate
indications.
Arthroscopic versus
open surgery is
comparable when the
correct indications
are utilized and the
surgeon has mastered
the techniques. It is
essential that we be aware of the pitfalls and the pearls of treatment.
Dr. Petersen is a fellowship-trained, board-certified orthopaedic surgeon with
Johns Hopkins Orthopaedics at MedStar Good Samaritan Hospital. He is a team
physician for the Baltimore Orioles baseball club, the co-director of the Division
of Shoulder Surgery for Johns Hopkins Orthopaedics and an associate professor in
the Department of Orthopaedic Surgery at the Johns Hopkins School of Medicine.
Dr. Petersen specializes in injuries and disorders of the shoulder, including sportsrelated injuries, rotator-cuff disorders, arthritis and fractures.
For more information, please visit:
• www.hopkinsorthogsh.com
© 2013 The Johns Hopkins University, The Johns Hopkins Hospital, and Johns
Hopkins Health System, all rights reserved.
15
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