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Welcome to the Blog site for Wellington Ortho & Rehab Associates, Guelph's Sport Medicine Specialists. This blog will chronicle the development of Guelph's most comprehensive and integrated rehab and injury care centre. Orthopaedics, Physical Medicine, Physiotherapy, Athletic Therapy, Massage Therapy and Chiropractic/Active Release Therapy. News, educational posts and innovative new products for your ongoing care and skeletal well-being. Feel free to comment or become a follower for alerts when new content is posted.

Wednesday, March 20, 2013

Meniscal Tears: Physio vs. Arthroscopic Surgery




Symptomatic osteoarthritis is generally acknowledged to be the commonest cause for middle-aged patients, presenting to medical care with knee pain.  Within this same age group, meniscal “cartilage” tears are also common, present in roughly 35% of patients over 50 years of age, usually with minimal symptoms. Given that these conditions often occur together, it is sometimes quite challenging to sort out which is the principal cause for ongoing knee symptoms.

Arthroscopic knee surgery is generally considered to be ineffective for the treatment of osteoarthritis (wear and tear arthritis). There remains some belief that arthroscopy can be helpful for the treatment of meniscal (cartilage) tears.

A well designed, multi-centre randomized, controlled trial published yesterday in the New England Journal of medicine challenges the notion that arthroscopic surgery is any better than physiotherapy, for the treatment of knee pain in those with both arthritis and a meniscal tear.  This study screened a large number of candidates, enrolling 351 patients that consented to participate.  Patients over age 45 years of age, with both knee arthritis and meniscal tears had to meet strict study criteria to participate. Patients were then randomly assigned to treatment consisting either of physiotherapy alone or arthroscopic surgery followed by physiotherapy.

Arthroscopic Partial Meniscectomy (Surgical group)
Surgeons performed an arthroscopy with partial meniscectomy by trimming the damaged meniscus cartilage back to stable tissue. Surgeons also removed loose fragments of cartilage and bone (also known as debridement).  Bracing was not used. Patients were then referred to physiotherapy for a postoperative program using the same protocol used in the physiotherapy group, described below.

The treatment group was based on literature supporting the effectiveness of land-based, individualized physiotherapy along with progressive home exercise for patients with knee osteoarthritis.  The 3 stage protocol was designed to address issues typically present in arthritic knees.  Patients were encouraged to attend physiotherapy sessions once or twice weekly and perform exercises at home. Pace and progress varied, with the program usually lasting about 6 weeks.
In both the arthroscopic-partial-meniscectomy and physiotherapy groups, patients were permitted to take acetaminophen and/or non-steroidal anti-inflammatory agents as needed. Some patients in both groups received cortisone shots over the course of the trial.

Looking at outcome scores for pain and overall function, both treatment groups showed similar improvement at both 6 and 12 months into the study.  There were no significant differences regarding adverse outcomes. About one third of the physio patients chose to have surgery during the treatment period, presumably for nonresponsive symptoms. Similar numbers from both groups went on to have knee replacements over the relatively short period studied.

My take*…
These findings help us deal more objectively with the relatively common situation in which middle-aged present with both meniscal AND osteoarthritic findings.  In the absence of mechanical locking, most patients should undergo a trial of physiotherapy and/or home exercise, before considering arthroscopic surgery.  Surgery warrants consideration for patients that fail to respond to non-operative treatment, but patients should realize that results are by no means guaranteed.  Further, well-designed scientific study is necessary to try and identify subgroups that would benefit more predictably from surgical intervention.

Full Scientific Article -link

K McKenzie MD
*The opinions expressed here are those of the writer, at the time this article was posted.  These opinions are presented for education and discussion purposes only and are not meant to constitute direct medical advice.  Individual patients/results may vary.  Patients are strongly encouraged to seek professional medical advice before deciding on treatments options.


Saturday, April 28, 2012


Embracing Re-Form

In early April, my orthopaedic practice, in conjunction with Wellington Ortho & Rehab became the first Canadian centre to offer the innovative DJO-Exos® bracing system as part of their expanding array of fracture management products.

Exos is the only bracing system that offers “a removable, adjustable, reform-able and waterproof solution for the treatment of fractures and other injuries (conditions) requiring stabilization.  I had a chance to get some hands-on time with this system last month and I was very impressed.

Exos is a heat moldable, rigid brace that performs the essential functions of a conventional cast.  Using a simple oven system, the brace can be warmed to the point of being almost rubbery in consistency.  Upon initial application, the brace can be gently molded for a snug, comfortable custom fit.  Now here’s the magic…  over the next few minutes, the brace hardens to a firm, cast-like consistency, fully capable of supporting the injured part.  Using the Boa® dynamic compression closure system, the brace can be tightened or loosened as required, maintaining a secure and comfortable fit.

Exos Short Arm Fracture Brace

How does Exos stack up against conventional casts?


Plaster/Fiberglass Cast
Exos
Rigid immobilization/protection
Yes
Yes

Light weight

Fiberglass-Yes
Plaster-No

Yes

Radiolucent, able to clearly xray through the device without removal

Fiberglass-Yes
Plaster-partially

Yes

Water-proof (fully submersible)

Fiberglass-Yes (with specialized, bulky lining)
Plaster-No

Yes

Adjustable, accommodates for swelling and/or muscle loss (atrophy)

No

Yes

Easy Removal

No-requires cast saw

Yes-but can be locked if indicated

Re-moldable, re-formable

No-requires removable and re-application

Yes

Allows easy examination/inspection of the fracture/injury site

No

Yes

Skin and/or cast cleaning to control odor

No

Yes

Ability to start rehab therapy earlier in the healing process (if indicated*)

No

Yes

Saw-less Removal

No

Yes


From a medical perspective, this system offers advantages over conventional casting.  From a patient perspective, the advantages are even more pronounced, leading one of my initial patient to ask “why would somebody want a cast when this (Exos) is available?”.

Exos braces can be fit and applied with referral from the physician managing your injury or by direct referral to my orthopaedic practice in Guelph, Ontario.  Call 519-837-2020, click here to book on line, or send us an email at "MyExosBrace@gmail.com" today so we can get you fitted for this remarkable product today!


Some important points to remember:

  • Exos® is a medical device and should only be used under the advice of a physician, when treating a medical condition.
  • Exos® may NOT be suitable for your specific fracture, ask your doctor.
  • Exos® braces require that users follow simple, but specific instructions.  Ask for your instruction sheet at the time of initial application.  If you have questions, ask!
  • Skin irritation can develop, particularly if device is over-tightened.  Please follow instructions given at initial application. 
  • Consult your physician immediately should a problem develop or should you have concerns.

Thursday, February 2, 2012

Therapeutic Massage, a Scientific Basis?

Ken McKenzie MD, FRCS(C), Orthopaedic Surgeon


Patrick Stiles, our Director of Massage Therapy has always been our most vocal advocate for the therapeutic benefits of massage therapy. Massage as a popular therapy has struggled to gain respect as serious medicine. In his popular blog post last year, “Massage Therapy, More Than Just a Back Rub”, Patrick points out the therapeutic benefits of massage as well as detailing the intense training required to become a Registered Massage Therapist. He now has additional ammunition. A study just released (study) shows that massaging muscles after hard exercise decreases inflammation and helps your muscles recover. This study also hints that massage after exercise may help relieve soreness, and may also help muscles become fitter faster.

In the study, researchers put 11 young men through a hard bout of exercise. Following their workouts, each got a 10-minute, Swedish-style massage, but only on one leg (the other leg was rested and used for comparison). Researchers sampled muscle tissue from both legs before and after exercise. They used gene-profiling techniques to look for chemical changes in muscle cells.

The lead author for the study was researcher Mark A. Tarnopolsky, MD, PhD, professor of pediatrics and head of Neuromuscular and Neurometabolic Disease at McMaster University in Hamilton, Ontario.

Dr. Tarnopolsky and his team found two main differences between the legs that were massaged and those that were not:

1. Massage switched on genes that decrease inflammation. Many painkilling medications also work by blocking inflammation.

2. Massage activated genes that promote the creation of mitochondria, structures that are the energy factories inside cells. The fitter a muscle cell is, the more mitochondria it tends to have.

The Significance of This Finding

In recent years, a number of studies have shown that remedies for muscle soreness that work by turning down inflammation (like ice baths or anti-inflammatory medications), may also have a downside. They may block some of the inflammatory pathways muscles use to repair themselves and grow.

Regarding muscle fitness, "If someone starts an endurance exercise training program, after two or four months of training, depending on the intensity, you essentially double the volume of mitochondria in muscle," says Dr. Tarnopolsky. Mitochondria, he says, help the cell to take up and use oxygen. Exercise and massage both seem to enhance mitochondria and the ability to use oxygen efficiently.

As interesting as these findings are, however, there's still a lot the study is unable to say.

Priscilla Clarkson, PhD, who studies post-exercise muscle soreness, cautions that the study didn't look at whether massage actually improved pain.

What's also not known is whether massage may still be helpful if a person gets a rubdown hours or days after a hard workout instead of just minutes.

In 2010 a study published in The Journal of Alternative and Complementary Medicine found that Swedish massage boosted immune function and decreased stress hormones compared to a placebo.

The study is published in the Journal Science Translational Medicine.

Ken McKenzie MD, FRCS(C), Orthopaedic Surgeon