How nutrition can help in the healing process. It really is what you eat!

We perform a variety of surgery on a weekly basis, anything from tendon repairs to plating broken bones.  All patients having surgery have one thing in common--everyone wants their surgery to heal!  All surgeons want their patients to do well after operations.  So how can this be done?  Well although there are no guarantees, surgical patients can put themselves in the best possible scenario for healing starting right in their own homes.

First, any type of wound or surgical incision must have adequate blood flow to heal.  Certain diseases can impair the amount of healthy blood flow to areas of our bodies.  These diseases include diabetes, high cholesterol, and high blood pressure.  The better these diseases are managed the better chance a wound has to heal.  Also, the better a blood supply to an area the less likely it is to become infected.  I like to use the analogy of a pond.  If a pond or lake has a stream feeding it fresh water the lake stays clear and the fish stay happy.  However, if the stream gets cut off the pond gets cloudy and algae starts to grow, before you know it all the fish are dead. The same happens with our wounds and blood flow, if the veins and arteries stay clear our wounds will stay clean, however if they are blocked by cholesterol or high pressures we get infection.

The foods we eat also play an important role in healing.  Dangerous molecules occur in our bodies called "free radicals."  These molecules like to steal pieces of other molecules in our tissues leaving them damaged and prone to diseases.  Antioxidants protect our tissues from free radicals by giving the little devils the particles they are trying to steal thus preventing damage.  These giving little antioxidants are better known as Vitamin C, Vitamin E, Vitamin A, and Beta-Carotene to name a few.

They can be found in the following foods:

Vitamin C: citrus, kiwi, strawberries, bell peppers and broccoli
Vitamin E:  almonds, avocados and olive oil   
Vitamin A/Beta-carotene:  carrots, sweet potatoes, kale, chard and papayas
 (Boost Your Immune System with Antioxidants)

Protein is not only a major building block of muscle and other structures in our bodies but it is also essential for wound healing.  Protein is an ingredient in a substance called collagen.  Collagen fibers are placed across wounds by the body to provide stability.  More and more collagen is added over the first 6 weeks after an injury or surgery.  As the collagen is applied the wound becomes more stable and stronger.  There are many sources of protein in our diets including commonly known sources likes nuts, meats and beans.  However, other good sources like edamame (soybean), quinoa, and chickpeas are great choices too!  

Foods are unfortunately not the only thing we as humans are putting into our systems.  Nicotine plays a huge role in the healing of tissues in our body.  Both bone and soft tissue are effected by smoking.  Not only are smokers more likely to experience certain injuries, like rotator cuff tears and fractures, but they will also take longer to heal from those same injuries.  Smoking restricts blood supply to the tissues of our body, and as we have discussed adequate blood flow is vital to healing wounds.  Blood flow is also vital to healing fractures and tendon repairs.  If a fracture site is not given the correct nutrients from the body it will not heal, and it will go on to become a "non-union."  This often requires surgery for plating to set the bones in place correctly.  However even with plates bones may still not heal.  Many spine surgeons will actually require their patients to quit smoking before they will perform certain spine procedures because the risk of the spine not fusing post operative.      

If your mother told you "eat your vegetables!"  You should listen!  We all know that mother knows best and when it comes to healing wounds, think healthy diets and no smoking.  Feel free to ask questions.

Cheers!

Sources:

http://www.elsevieradvantage.com/samplechapters/9780323034708/9780323034708.pdf
https://www.nlm.nih.gov/medlineplus/antioxidants.html
http://www.healthchecksystems.com/antioxid.htm
http://www.woundsinternational.com/media/issues/217/files/content_182.pdf 
http://orthoinfo.aaos.org/topic.cfm?topic=a00192
http://news.wustl.edu/news/Pages/7921.aspx

Osgood Schlatter Disease-It Hurts When I Jump!

Osgood-Schlatter disease occurs in adolescent athletes during growth spurts.  As my young cousin Kendyll can attest it hurts! Often found in running athletes like soccer and basketball players OSD can be frustrating to children throughout their childhood until they reach skeletal maturity.

The bones of the body grow in areas called "growth plates."  Growth plates are cartilage collections located at the ends of bones. These centers for growth are the last portion of the bone in children to harden--which occurs at skeletal maturity.  Because the cartilage is softer then the surrounding bone, injury is more likely to happen in these areas. OSD is inflammation of the growth plate just below the knee cap.

Figure #1

The tibia is the shin bone in the lower leg.  It helps form the knee joint and contains a growth plate just below the knee.  The growth plate is at a site called the "tibial tubercle"  a tubercle in the body means a bump in the bone that has a tendon attached to it. Note in figure #1 that the patellar tendon attaches to the tibial tuberosity. As a young soccer player repeatedly runs or jumps the patellar tendon pulls on the growth plate on the tibial tuberosity and can cause pain and swelling. (Figure #2)     

Figure #2

Treatment can include nonoperative management with rest, stretching, strengthening, physical therapy, anti-inflammatory medications, ice, and bracing with a Cho-Pat strap.  The Cho-Pat (figure #3) strap places pressure on the patellar tendon during activities and can provide some relief.       

Figure #3

Unfortunately, even with treatment symptoms may continue to come and go until the child reaches full bone growth.  This maybe be anywhere from around age 14-16 depending on sex.  Even with the resolution of symptoms individuals may have a prominence of the tibial tubercle for their entire life.  This is caused by the trauma to the growth plate which may never totally fuse to the bone underneath.  This is called a "fibrous union" meaning that the growth plate is held on by tough tissue rather then bone. Adult patients usually have no symptoms related to the non-fused growth plate.   

Very often we xray patients in the office and see old evidence that they had OSD as a child.  It no longer effects them but they may have some bulging of the tibia in that area.  Their xray looks like figure #4. Note that the tibial tubercle is slightly separated from the rest of the tibia.  A minority of adults may have some pain with kneeling in this area, and rarely have the small bone growth removed surgically if symptoms are severe.   

Figure #4

Osgood-Schlatter disease can be a struggle for children until they reach the end of their growth.  However with some activity modifications and treatment they are able to have a full active childhood.  Once they achieve full bone maturity they rarely have continued symptoms and can continue with an active adult life.  

Next Topic: How nutrition can help in the healing process. It really is what you eat!

Sources:
http://kidshealth.org/parent/general/aches/osgood.html#   


http://www.mayoclinic.org/diseases-conditions/osgood-schlatter-disease/basics/definition/con-20021911

You Are An Ironman...

An Ironman is a 140.6 mile race that most would agree is the ultimate test of will and endurance.  2.4 mile swim, 112 mile bike, and 26.2 mile run--it's all a bit crazy isn't it?  Well for the last year everyone in our office has been a witness to the preparation, skill, and unbelievable determination it takes to compete an Ironman Triathlon. My friend, and our co-worker Elise just finished her first and we all couldn't be more proud of her.  I thought this might be a good opportunity to both congratulate Elise, as well as use her as an example of cross-training at its extreme.

We often have patients that are runners, this may consist of anyone from someone training for their first 5K to competitive club triathletes like Elise.  The runner may have a variety of lower leg complaints depending on their level of conditioning.  A few of the most common are anterior knee pain and medial tibial stress syndrome (shin splints).  Anterior knee pain is pain over the front of the knee in the area of the knee cap also know as the patella.

The patella is positioned in the front of the knee and has attachments for the quadriceps tendon at its superior portion and the patellar tendon at its inferior. The patella is involved in the flexing and bending of the knee, and with repetitive motions both the patella and the groove it sits in can become irritated or damaged.  As you can image running is one of these activities, actually any activity that involves flexing your knee puts pressure on the knee cap. Squatting, kneeling, jumping, running, wearing high heels (mom :) all put increased pressure on your patella.  In order to treat pain involving the patella you have to first find the reason for the pain.  This can include weakness in muscle groups around the knee, wear in the cartilage on the patella, patella alignment issues, or even modifying the very activities we love to do.  


Medial Tibial Stress Syndrome (MTSS) is what many of know as shin splints.  Symptoms include a painful inflamed area along the inside border of the shin bone (tibia).  Often the person experiencing these symptoms has recently changed their level of activity in some way.  I personally experienced MTSS in high school basketball after running on our hard court/hallways.  As medical providers we always have to remember to rule out a stress fracture in anyone that has the symptoms of MTSS.  There is too much overlap in the symptoms and if you ignore MTSS it can lead to a stress fracture.  If x-rays are negative for fracture treatment will often consist of ice, rest, stretching, possible physical therapy, and modification of activities, as well as a good foot wear analysis.    

 

Standing with her finisher medal

I always tell you about the conversations I have on a daily basis with patients.  Activity modification is another common topic.  This is where Elise comes to light again--Swim, Bike, then Run.  I am a strong supporter of cross-training to allow the knee to recover after activity.  Runners love to run!  However, for the life of a knee taking miles off of the joint with none pounding exercise like swimming, elliptical, and cycling is important.  I consider these "knee friendly" cardio conditioning.  Perhaps if more of our runners turned into triathletes we would have less knee pain.  Will we ever know?


Next Blog Topic: Osgood Schlatter Disease-It Hurts When I Jump!

Elise crossing the finish line.

Total Knee Replacements--Why so Spooky?

This topic is brought to you by popular demand!  I've had great deal of requests for a topic on total knee replacements or as we call them in the ortho world TKAs (Total Knee Arthroplasty).  TKAs can seem overwhelming and downright SPOOKY if you are faced with the possibility of surgery.  Let's see if we can dust some cobwebs off the common myths about TKAs and reveal the truth hidden underneath!

I have a conversation about the compartments of the knee with patients on a weekly basis, so this may sound familiar to some of you.  The knee is separated into three compartments, the inside of the knee (Medial compartment) outside of the joint (Lateral compartment) and the knee cap joint (Patellofemoral compartment).   The knee may wear in one, two, or all three of those compartments and the amount of wear determines what surgery is recommended.

There are two types of cartilage within the knee. The Meniscus the large shock absorber between the bones and Articular cartilage which covers the ends of the bones.  Articular cartilage acts in a similar way to enamel on our teeth, it in itself does not feel pain, but when it is worn away the bone beneath feels pain.  This is considered arthritis (just like a cavity in your tooth) and can be very painful.

When you have this break down in cartilage in one of the compartments in the knee that one area of the knee can be replaced.  This is called a Unicompartmental Arthroplasty or "Half Knee."   I personally think we should call them "1/3 knee replacements" but my opinion doesn't seem to count for much!  The problem is when individuals begin to develop damage in two sometimes all three compartments of the knee.  This is global or total knee arthritis, and is when surgeons recommend a TKA to replace the entire knee.

By the time a patient needs a total knee replacement it is usually easy to see on xray studies.  As you can see on my background images for the blog the patients' knees are pretty healthy with good space between the thigh bone (femur) and shin bone (tibia).  He did not need a TKA he was actually a young healthy teenager.  In contrast, this knee shown below, has no joint space at all in the medial compartment, or "bone on bone" arthritis.  The patient also has bone spurs that have formed at the ends of the femur and tibia at the joint line.  The body will try to put down bone in areas where cartilage has been worn away.  It is a protective mechanism in the body but unfortunately backfires and causes us to lose range of motion.     

Total knee arthroplasties as we know them were developed in the early 1970s.  The surgery continues to be tweaked and modified on a regular basis but many of the concepts are the same.  We still replace the end of the femur and the tibia with metal components and a plastic spacer replaces the meniscus.  There are many companies on the market today and most will tell you their knee components are the best around.  I compare this to care manufactures.  Many are built on similar constructs with different bells and whistles, but all will drive you from one place to another.  I  think the most important concept is that your surgeon is comfortable working with the implant.  Most joint surgeons have a preferred brand or two that they feel works best for their patients and has had the best outcomes in their hands.


There are two major distinctions when it comes to total knee replacement implants--cemented vs press fit components.  The type of component a surgeon uses often is related to where he/she was trained.   A "press-fit" component get its name because it is actually impacted or pressed onto the ends of the bones.  The idea is that the patient's own bone will actually adhere or grow into the metal components forming a stable construct.  This is good for younger patients who may need a second replacement procedure early in their lifetime because revising these implants is a little easier.  A cemented implant requires gluing or cementing the metal onto the bone.  This also forms a stable construct, and maybe good for older patients or patients with poor quality bone.  The cement allows for a secondary fixation when poor quality bone may not be quite enough.

TKAs are a fascinating topic and relevant to so many people.  I hope this provides a background on the procedure and need for a replacement.  As I began writing this article it became clear that it would be too large for one post.  We have so much more to discuss!! Hospital stays, rehabilitation, risks vs benefits of surgery.   I will have to post a TKA Part Two in the near future.  Feel free to ask questions if you would like them included in that article.

Next post in two weeks is a surprise...     

   

For more info on TKAs check out the AAOS webpage here





Sources
Ranawat, C. (2002). History of Total Knee Replacement. J South Orthopedics Assoc, 11(4), 218-26. Retrieved September 22, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/12597066

Happy National PA Week!!

Every year from October 6th-12th is national Physician Assistant week.  Since you are my friends, family, and patients, I thought it only fair to celebrate with you!  Several times a year I get asked questions about if I like my job, what I do, and how long I went to school, etc. This is a great opportunity for me to answer a lot of these questions and shine some light on a great career. 

The Physician Assistant profession was born out of the Vietnam War.  Many soldiers, specifically medics came home from war with great skills but had no place in the states to use their new knowledge.  In 1965 Duke University started the first Physician Assistant program with 4 Navy corpsman.  My own alma mater, Saint Louis University, was one of the first 12 PA programs in the nation opening in 1971.  Most programs have since transitioned from bachelor degree programs to masters level degree programs across the country.  There are now 170 PA programs and counting, the state of Missouri having 3 SLU, Missouri State, and the newly formed UMKC program. 

Getting into the PA school of choice can be a challenge, just ask my family!  There are interviews to drive to, essays to write, and lots of medical hours to log.   To begin you will have to fill out the online application called CASPA (Central Application Service for Physician Assistants) This is one application you fill out online for all the schools you are interested in attending.  It really simplifies the process.  If you would like more information on how to become a Physician Assistant take a look at our national organization the AAPA's website they have an overview of the process here.

The career is becoming increasingly popular.  Forbes Magazine named PA the #1 Most Promising Job of 2015  and we also make the top 10 list of the Best Jobs of 2015 in US Money and News Report.  The Bureau of Labor and Statistics shows the job growth for PAs from 2012-2022 as 38%!  That is more than triple the average job growth rate.

It is obvious that I am passionate about my career and continue to encourage young people to consider going into the field.  This week I would like to take note of the best part of my job.  As with all things in life the people you meet along the way are what you hold most dear.  I personally celebrate my fellow PA's this week because they are some of my very best friends and I am proud to know them!

National AAPA Conference Class of 2010 Atlanta Aquarium

PA School Kick Ball Team

My best friends at Graduation from SLU

Catching up with classmates

Follow up in two weeks for my Halloween topic...Total Knee Replacements--Why so Spooky?
    









Citations
-SLU PA Dept History
-http://pahx.org/timeline.html 

Good vs Evil Internet Searches

If you search Google for the term "ankle sprain" you will get one billion hits, including anything from Wikipedia to what high profile athlete just hit the DL.  How do you sort for credible data through all the bad?  The internet is a great tool full of valuable information, however when it comes to looking for good orthopedic information it can be a little daunting.  Let's look at some of my favorite ways to get good solid information on a variety of topics. I will also show you a brief overview of how to look for published articles on PubMed.

My two favorite sites to visit for general information are administered by the Mayo Clinic and the AAOS.  The Mayo Clinic provides small informational articles on just about every ailment, including treatment, symptoms, and a section on "preparing for your appointment."  The AAOS (American Academy of Orthopedic Surgeons) has a great educational website that allows you to select a problematic area from a skeleton which then leads you to different topics.   The AAOS website also has a large library of videos and animations for those of you that like visuals.

http://orthoinfo.aaos.org/

Finally, a quick look at PubMed searches.  I could do an entire post on how to look up credible scientific papers, but I don't want to bore you with too many details.  Let's start with the basics.  PubMed is provided by the US National Library of Medicine and allows people free access to medical and scientific abstracts and journals.  Not all the articles are free but you can view the abstracts (a sort of scientific summary) on almost every paper.  To search--go to PubMed, you will note a search bar at the top of the page.  The search bar is predictive, much like an iPhone it will try to finish your thoughts.  Type "ankle" and watch as it fills in all the possible searches including "sprain."

Once you select "ankle sprain" you will notice you get over 14,000 articles that meet your criteria. Now we must apply some "filters" to narrow our search.  On the left hand side of the screen you can select different options to apply to your search.  I usually apply publications in the last five years to make the papers relevant, humans so the topics relate to human beings not animals, and free full text so you can read the whole paper if you choose.  By doing this I narrowed our list down to 390 papers.

Ok, that's a lot of information for this round.  I will leave you there, feel free to ask any questions.

Check in next blog for the topic...Happy National PA Week!


Citations:
http://www.nlm.nih.gov/services/pubmed.html     

Introduction

Welcome to my brand new Orthopedic blog.  I decided to start this space for several reasons, but I think a recent patient encounter helps shine light on the need better than anything. 

Often, patients will ask me about topics they have read on the internet from a variety of sources including blogs.  Actually the source that makes me cringe the most is the blog—unfiltered information from unchecked sources.  Scary! And that’s right where this particular patient had found themselves; up at night reading blogs about all the terrifying complications of surgery.

My family will tell you I have a bit of a worrying streak myself, so I can totally relate to this thirst for knowledge on a topic.  However, our now completely freaked out patient friend has read too much.  I found them the next day in a bad place, full of anxiety and misinformation.  That is when he/she encouraged me to start my own blog where I could put good information out to my patients and answer questions.

So, here we are--our new orthopedic frontier.  The Bare Bonez- an interactive forum where we can discuss ideas and share knowledge on a variety of topics.   I will write on some of the more commonly asked questions I get on a daily basis,  interesting new research coming out, and respond to feedback.  

Thanks for following and come back to check out my next topic…

-Good vs Evil Internet Searches    

Kelli PA-C