Scientific Basis for Orthopedic Care PDF

Scientific Basis for Orthopedic Care PTR 629  PT Exam Objective Exam- Physical Exam Subjective Exam- History Observation Current Symptoms and MOI Gross Movement Assessment Past History...

Scientific Basis for Orthopedic Care PTR 629  PT Exam Objective Exam- Physical Exam Subjective Exam- History Observation Current Symptoms and MOI Gross Movement Assessment Past History AROM General Health- Systems Review PROM Psychosocial Gross Strength Testing- MMT Patient Goals Special Tests Subjective Outcome Measures Joint Mobility Assessment Palpation Functional Tests  Subjective Exam Who- Patient History- MOI What- Can we identify structure?- Tendon, Bone, Lig, Etc Where- Location of injury- Is pain local? Referred? When- Acute vs. Subacute vs. Chronic Why- Type of and amount of stress on structure How- How will you treat? What stress will you use to treat?  Objective Exam How are symptoms reproduced? 1) Symptoms with AROM and PROM in same direction? 2) Symptoms with AROM and PROM in opposite direction? 3) Symptoms with resisted movement? 4) Change of symptoms with posture? 5) Palpation?  What Type of Tissue? Bone Fibrous Connective Tissue Ligament Tendon Articular Cartilage  Bone Mechanical Properties Type of Loading Wolff’s Law Compression “Bone adapts to stress placed on it” Tension Amount, type, and Torsion or shear direction of load determine how bone is Speed and amplitude of produced force is important  Bone- Mechanical Properties Compression Best load for bone Results in bone formation Moderate consistent force is best Bone is strongest when loaded through compression  Bone-Mechanical Properties Tension Bone has good strength against if loaded parallel to long axis of bone Can result in bone resorption  Bone- Mechanical Properties Torsion Bone is weak to this force Causes fractures easily Small loads can increase bone strength  Bone- Mechanical Properties Shear Bone is weakest to this force Causes fractures easily Small loads can increase bone strength Trabeculae formation  Bone- Healing Proper Alignment Adequate fixation Good nutrition How is the blood supply? Compression increases bone growth  Adequate Fixation Reduction Closed Open Internal Fixation (ORIF) External Fixation (OREF)  Closed Reduction Can proper alignment be attained without surgery? May reduce with or without anesthesia Cast, splint, boot or brace to hold position  Open Reduction Surgically (open) realign bone for proper healing If bone cannot be reduced and stay aligned without surgery Mid shaft of long bones can be difficulty to reduce Fractures close to ends of bones secondary to muscle attachment and resting tension in muscles Smaller bones with little blood flow  ORIF Rods Pins and wires Screws Plates  ORIF Increase chance of infection (possibly years later) Large incisions (healing time and ability) May heal faster than OREF May not lead to long term strength Usually permanent, but may be removed  External Fixation Pins or wires used to secure an external scaffolding Can use compression or traction Post-traumatic, limb reconstruction, limb lengthening, arthrodesis, limb salvage Less soft tissue and periosteum disruption Temporary May lead to increased long term bone strength Ilizerov Frame  Bone Healing Inflammation Soft callus Hard callus Remodeling  Bone Healing- Milestones First 3-4 weeks Soft Callus Phase Fragile Continue to immobilize Stable once phase is over  Bone Healing- Milestones 4-6 weeks Hard Callus Phase Can resume normal activity once fully stabilized 3-4 months Hard bony union 1-2 years Remodeling  Fracture Types Stress Fracture Intraarticular Extraarticular Simple Complex Comminuted Closed Open  Stress Injuries Factors Loading factors- Biomech, training, strength, surface, shoe/orthotics Factor that modify ability of bone to resist load- Genetics, nutrition, endocrine status, activity history, disease, meds Rehab Implications? Paterno, et al 2009  Fibrous Connective Tissue Tendon and Ligament Fibroblasts in extracellular matrix structure Histology: Fibroblasts- 20% Structure: Collagen, Elastin, Ground Substance- 80% Mechanical Properties: Davis’s Law Tendons and Ligaments  Tendons Collagen is more organized More specific function Carry tensile forces from muscle to bone Compress bone when acting as pulley  Ligaments Less volume of collagen and less organized Function may be less specific Resist multiple directions of mvt Mechanoreceptors- Proprioception  Mechanical Properties Fibrous Connective Tissue Compression is destructive Respond well to tension Weak with torsion or shear  Mechanical Properties Viscoelasticity Time dependent mechanical behavior Stress and strain relationship is not constant Creep Stress Relaxation Stress/Strain Kisner and Colby,2018 Creep Stress Relaxation  Tendinopathy Reactive Tendinopathy- Cells activated, proteoglycans increased Dysrepair- Extracellular Matrix disruption with vascular ingrowth Degenerative Tendinopathy- Cell death, ECM degenerates, neovascularization  Tendon Healing Need loads to heal Tendons synthesis and increased stiffness with load Start with isometrics, then isotonic (eccentric and concentric) then plyometric Isometric and isotonic exercise decrease pain Magnusson, 2019 Avoid wrapping of tendon, avoid end range exercises with insertional tendinopathy Rio, 2015 and 2017  Breda et al 2021 76 psubjects with patellar tendinopathy randomized into 2 groups Eccentric exercise and progressive tendon loading exercise Conclusion: “In patients with PT, PTLE resulted in a significantly better clinical outcome after 24 weeks than EET. PTLE are superior to EET and are therefore recommended as initial conservative treatment for PT.” Figure 2 Breda Et al, 2021 Figure 4  Tendon Rehab Do not completely rest- decrease load to beneficial levels No compressive loads No rapid loads Do not stretch early Do not ignore pain- Avoid more than 2 point increase Do not rely on passive treatments Takes 12 weeks for tendon changes and 6 months for significant change Cook, 2018  Ligament Injury Grade 1- Microscopic tears in substance with no effect on stability Grade 2- Macroscopic tear involving a partial tear- decreased joint stability, but ligament still partially intact Grade 3- Complete disruption- significant laxity in direction of motion that ligament restrains  Intra-articular ligs Limited ability to heal Surgical repair needed for non-copers Healing depends on type of repair Graft normally strongest initially Graft then degrades and “ligamentizes’  Normal Healing Major Milestones 0-4 weeks Structurally weak Protected ROM Minimal strength training  Normal Healing 4-6 weeks Structural union occurs Begin to achieve normal ROM BE CAREFUL!!!!  Normal Healing 6 weeks to 3-4 months Protected strength training 3-4 months to 8 months Fibers are becoming stronger Full ROM strengthening Possible start athletics  Normal Healing 8 to 12 months Remodeling of Fibers Must load fibers Return to full activity Full ROM, neuromuscular integration, strength “Ligamentization”  What effects healing? Age Co-morbidities Extent of injury Site of injury Intra or extra-articular  Cartilage Articular Cartilage- Hyaline Cartilage Chondrocytes Extracellular matrix- Collagen (Type II), proteoglycan, small amount of elastin, water Avascular and not innervated  Cartilage 4 zones- Superficial, transitional, deep (radial), calcified  Cartilage Injury Single insult vs. degeneration High-impact force vs. Repetitive sub-threshold loads Compression- Responds well to slow, low loads- high speed and high force is destructive Torsion and shear- Can cause tears  Cartilage Injury Chondral damage without visible disruption (cartilage at risk) Disruption of cartilage alone Disruption of cartilage and subchondral bone (osteochondral injury)  Cartilage Classification The Outerbridge classification is a grading system for joint cartilage breakdown: Grade 0 - normal Grade I - cartilage with softening and swelling Grade II - a partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameter Grade III - fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cm Grade IV - exposed subchondral bone  Surgical Procedures Microfracture Matrix-Induced Autologous Chondrocyte Implantation (MACI) Osteochondral Autograft Transplantation (OATs) Osteochondral Allograft Transplantation  Microfracture Most common- Tears 65, poor knee alignment, RA, non-full thickness tears Complications: Mild transient pain, “Gritty” sensation, catching, effusion Zamborsky, 2020 Osteochondral Autograft Transplantation (OATs) Transfer of Cartilage and Bone “plugs” from NWB’ing portion of joint to repair site Better long term outcomes than microfracture Indicated for young active patients without severe OA or RA and good donor site  Matrix-Induced Autologous Chondrocyte Two-Step Procedure Implantation (MACI) Chondrocytes Harvested From Patient in First Surgery Chondrocytes are Expanded in a Culture Then Seeded into a Collagen Scaffold During a Second Procedure the Matrix is Cut to Fit and Secured with a Fibrin Glue Indicated for 18-55 y/o, Full Thickness Tears Less Than 3x5cm Without Severe OA Brandon, 2018 Crecelius, 2021 Post-Surgical Rehab Crecelius, 2021  Surgical Research Return to Sport: Microfracture: 64%, MACI 74%, OATs 84.4% Return to pre-injury level: Microfracture 55.1%, MACI: 69.3%, OATs: 62.3% Microfracture has the Highest Rate of Failure Robinson, 2020  What does all of this mean? We need to think about speed, duration, direction and amplitude of loads that we use in rehab!!!  What are the goals? Alleviate pain and swelling Restore ROM Increase strength Restore neuromuscular control Return to function  References Breda SJ, Oei EHG, Zwerver J, et al. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. Br J Sports Med. 2021;55(9):501-509. doi:10.1136/bjsports-2020-10340 Brandon J. Erickson, Sabrina M. Strickland, Andreas H. Gomoll, ,Indications, Techniques, Outcomes for Matrix-Induced Autologous Chondrocyte Implantation (MACI). Operative Techniques in Sports Medicine, Volume 26, Issue 3, 2018, Pages 175-182,I SSN 1060-1872,https://doi.org/10.1053/j.otsm.2018.06.002. Claes, Steven, et al. “The ‘Ligamentization’ Process in Anterior Cruciate Ligament Reconstruction: What Happens to the Human Graft? A Systematic Review of the Literature.” The American Journal of Sports Medicine, vol. 39, no. 11, Nov. 2011, pp. 2476–2483, doi:10.1177/0363546511402662. Cook JL, Ten treatments to avoid in patients with lower limb tendon pain. British Journal of Sports Medicine 2018;52:882. Crecelius, C. R., Van Landuyt, K. J., & Schaal, R. (2021). Postoperative Management for Articular Cartilage Surgery in the Knee. The journal of knee surgery, 34(1), 20–29. https://doi.org/10.1055/s-0040-1718605 Kisner, C and Colby, LA: Therapeutic exercise:Foundations and techniques, ed 7. F.A. Davis,Philadelphia, 2018 Paterno, M, Archdeacon, M. Is There a Standard Rehabilitation Protocol After Femoral Intramedullary Nailing? J Orthop Trauma 2009;23:S39–S46 Pathria, M, Chung, C, Resnick, D. Radiology. Acute and Stress-related Injuries of Bone and Cartilage: Pertinent Anatomy, Basic Biomechanics, and Imaging Perspective July 2016; 280(1): 21–38. doi: 10.1148/radiol.16142305 Rio E, Kidgell D, Purdam C, et al, Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine 2015;49:1277-1283. Rio, Ebonie; van Ark, Mathijs Docking, Se†, Moseley, G. Lorimer; Kidgell, Dawson, Gaida, Ja van den Akker-Scheek, Zwerver, Jo, Cook, Jill. Isometric Contractions Are More Analgesic Than Isotonic Contractions for Patellar Tendon Pain, Clinical Journal of Sport Medicine: May 2017 - Volume 27 - Issue 3 - p 253-259 doi: 10.1097/JSM.0000000000000364 Robinson, P.G., Williamson, T., Murray, I.R. et al. Sporting participation following the operative management of chondral defects of the knee at mid-term follow up: a systematic review and meta-analysis. J EXP ORTOP 7, 76 (2020). https://doi.org/10.1186/s40634-020-00295-xScott, A. Bachman, L, Spped, C. Tendinopathy: Update on pathophysiology. J Ortho Sports Phys There. 2015;45 ;833-841 Zamborsky R, Danisovic L. Surgical Techniques for Knee Cartilage Repair: An Updated Large-Scale Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020;36(3):845-858