Boning up on orthopedics

Setting fractures and treating infections used to be the main job of doctors treating musculoskeletal disorders.

Prof. Amos Peyser (photo credit: SZMC)
Prof. Amos Peyser
(photo credit: SZMC)
When the treatment of musculoskeletal disorders was first named “orthopedics” in the late 18th century, it dealt with the correction of deformities in babies and youngsters. University of Paris Prof. Nicholas André – the physician and writer who coined the term – even created the word from the French for “straight” and “child.”
In fact, until the middle of the past century, orthopedists were busy mostly with treating pediatric deformities like clubfoot and broken bones in people of all ages; in those days, fractures could be fatal. Today, the field is a highly sophisticated combination or surgical and non-surgical procedures for everything from congenital disorders, degenerative diseases and infections of the bone to tumors, curved spines, war and sports injuries and the replacement of diseased joints.
The fact that life expectancy has lengthened and too many people are obese has put more burdens on the skeleton, muscles and ligaments and increased the workload for orthopedists.
The first total hip replacements – in which synthetic implants are cemented to the bone instead of eroded joints – were offered 50 years ago in England, followed by knee replacements in rheumatoid arthritis patients the following decade. People who used to be confined to wheelchairs or dead at middle age are now romping around playing tennis and riding bicycles. Victims of severe fractures and children and adults of very short stature can be helped with external fixation of fractures with metal rings and screws turned gradually, thanks to the invention of a Soviet amateur, Gavril Abramovich Ilizarov. The technique has been improved since then, but it is still successfully used today.
Arthroscopy (keyhole surgery) on torn cartilage or joints enables patients to go home the same day following the minimally invasive procedure. Shoulders, wrists, ankles, feet and hands and spines can also be treated for pain and malformed and damaged bones, joints, ligaments, muscles and cartilage.
Metal and ceramics become almost-natural parts of the body.
SO GIVEN the exciting developments in the field, it wasn’t surprising that the fifth-floor Hedi Steinberg Auditorium was filled late last month when Jerusalem’s Shaare Zedek Medical Center held the first in its new Shishi Bari (Healthy Friday) series of lectures by some of its leading physicians. The event was addressed by SZMC director-general Prof.
Jonathan Halevy, who noted that as most in the audience were Jerusalemites, they did not have to be introduced to Shaare Zedek.
“We put much stress on training, updating, sophisticated equipment – and empathy, listening and talking to the patient and his family. Together with our Bikur Cholim campus, we have 1,000 beds and perform 25,000 operations a year. We also have over 100,000 visits to our emergency room, more than to any other in Jerusalem.”
Devoted to the subject of orthopedics and open free to the public, the three-hour event attracted hundreds of people, most of them past retirement and some using canes, walkers and wheelchairs. Even though the lectures were scientific, the doctors managed to make them understandable to laymen.
Prof. Amos Peyser is chairman of the eighth-floor orthopedics department, which is divided into units for treatment of the spine, arthroscopy and hand surgery.
“Before the Six Day War, we did mostly treatments for fractures, putting limbs in plaster and performing surgery to get rid of infections. There was nothing hi-tech like joint replacement,” he said. “In the Yom Kippur War, younger doctors got into their uniforms, while the older physicians remained on the job. Thirty-eight percent of all the wounded were treated at Shaare Zedek’s original campus on Jaffa Road. Today we have 39 doctors – 28 of them senior – plus 11 residents, in addition to physiotherapists and occupational therapists.”
The department recently obtained a PETCT scanner that makes it possible to see bone tumors much more exactly.
“We also treat children with congenital leg defects. And as a result of the heavy winter snow of 2013,” said Peyser, “we constantly had people who slipped on the ice that formed everywhere and suffered fractures.
We put eight orthopedists in the emergency room, and it took a month to deal with all the fractured limbs.”
Discussing congenital problems in children’s feet, Dr. Ehud Lebel – head of the pediatric orthopedic unit – dealt with issues for which orthopedics as originally named.
“Foot defects in newborns are not rare, but not everything needs surgery,” he said, adding that one out of every thousand newborns has a deformation of the lower limbs.
“This can overshadow a family’s joy over the birth. But with the development of modern orthopedics, there are ways to cope with a large proportion of these cases,” he said.
The bones in the body don’t stop developing, Lebel continued.
“In children, bone growth is aimed at creating the maximum balance of forces affecting them. There are extreme deformities that don’t fix themselves, but in many cases, what appears in newborns as a serious problem disappears during the child’s first few years.”
Club foot, also called congenital talipes equinovarus, is a congenital defect involving one foot or both. The deformed foot appears to have been rotated internally at the ankle. Without treatment, people with club feet often seem to walk on their ankles or on the sides of their feet. But fortunately, with treatment, the vast majority of patients recover completely during early childhood and are able to walk and participate in athletics as well as patients born without the condition. About half the children born with clubfoot have two affected limbs, and males are twice as likely as females to have it.
“The biggest revolution in pediatric orthopedics,” said Lebel, “has been in the treatment of club foot. We used to perform surgical realignment, but if there is an operation, it can cause scars and harm the development of bones or blood vessels, and the deformity can return. But now we know that the foot can be made to grow straight even without surgery. The foot can be placed in a special plastic cast from the toes to the groin, making use of natural growth and causing the lengthening of the ligaments. A new plaster is put on every week up to a maximum of 10. The results are excellent. We have treated many children this way, and we have no doubt that in suitable cases, superfluous surgery can be avoided.”
Peyser, who is an expert in bone tumors, told the audience that even benign growths can cause a lot of pain.
“The word ‘tumor’ causes a lot of fear, but one must remember that the majority of them are not cancerous.”
He gave as an example a condition called osteoid osteoma, a non-cancerous bone tumor. It has a center of growing cells, called a nidus, surrounded by a hard shell of thickened bone. No one knows why these tumors form, said Peyser, but fortunately they do not metastasize through the rest of the body.
They tend to be small – less than 1.5 cm in size – and may occur in any bone in the body. They are most common in long bones, such as the thigh bone (femur) and leg bone (tibia). They are also found in the hands, fingers and spine. Osteoid osteomas may occur at any age, and are most common in patients between the ages of four and 25 years. Again, males are affected about three times more than females. In most cases, said Peyser, the growth is not visible in an X-ray, but more advanced technologies such as a bone scan or computerized tomography (CT) make it possible to diagnose and locate the osteoma.
The condition causes a dull, aching pain that is usually moderate but can get worse at night; over-the-counter pain medications such as ibuprofen and aspirin help relieve the pain. Sometimes, people suffer for years from this pain before complaining about it to their doctor.
The standard treatment for osteoid osteoma is surgical removal of the entire tumor, particularly the central core. Otherwise, the tumor may come back. This type of surgery is highly successful. However, surgery carries risks of general anesthesia, infection, bleeding and possible damage to surrounding tissues.
A newer treatment option of CT-guided radiofrequency removal of the nidus has been successfully used with few recurrences or complications. With only a small incision made in the skin as the patient has a spinal block and sedation or general anesthesia, the site of the tumor is identified and a radiofrequency probe is inserted into the tumor. The probe heats the tumor tissues to about 90 degrees C, killing them with minimal damage to surrounding tissues. The two-hour outpatient procedure is followed by two hours of recovery, and then the patient goes home. Shaare Zedek has treated some 90 such patients this way so far.
The department head recalled a 21-yearold soldier who complained of pain in his right knee. A CT scan showed he had a hole in the bone and a lump, a clear sign of osteoid osteoma.
“Previously, we used to do an open operation to remove several centimeters of bone including the tumor. Today, with the minimally invasive procedure, we use a tiny needle with radiowaves to perform ablation.
We create a grid to mark the place, make a two-or-three centimeter incision, take out the affected bone and send it for a pathology exam. Then we use acrylic glue for filling the hole.”
REUT SHEMESH, who is on the department’s physiotherapist staff, said, “We used only to treat sick people and try to extend their lives and improve their quality of life. Now there is also preventative care in healthy people.”
She strongly encouraged her audience to become physically active.
“It is recommended to do aerobic exercise that gets the heart pumping five times a week, and non-aerobic exercise for strengthening the muscles three times weekly. Age is no barrier. The type of exercise must be suited to the person, who has to enjoy it,” she added.
One can go to a gym and have a trainer, working in a small group. But you can also do it at home on a stationary bike, elliptical machine or treadmill, or even going up steps – or one can just walk in the neighborhood and lift weights. Swimming pools can be used not only for swimming but also for doing exercise in the water; this is very good for people with orthopedic problems.
If one swimming style is uncomfortable, try another. Shemesh strongly recommended Nordic walking with poles to lose calories.
DR. SHMUEL Weiss, who heads the foot and heel unit, discussed hallux valgus – commonly known as bunions – a deformity characterized by lateral deviation of the great toe. Although orthopedists do not agree on the cause, some say that women wearing tight, pointy high-heeled shoes is definitely involved. Pressure on the side of the big toe (hallux) forces it inwards towards and sometimes one over or under the other toe.
The tissues around the joint may become swollen and tender. Genetics is also a factor, said Weiss, “but flat foot or neurological problems could also be factors.”
Obviously, because of high heels, women suffer from it more than men. Eight out of 10 suffers have bunions on both feet. One can treat hallux valgus without surgery – wearing insoles and broad shoes or sleeping with special devices on your feet. Surgery for the condition used to require long rehabilitation, with the patient in a cast and confined to a wheelchair. But today, one can get special protective shoes that enable you after surgery to stand immediately, so the operation is now much more popular.
THE NEW head of the back unit in orthopedic surgery, Dr. Yair Barzilai, captured a lot of attention, as many in the audience seemed to suffer from spinal problems.
“The back pain can radiate to the hands and legs. One has to find the source of the pain. Sometimes there is also weakness and lack of feeling. We operate on people suffering from advanced paralysis or uncontrollable pain. Sometimes I release the nerve tissue from pressure as if I were a plumber. Sometimes I cut and redo sick vertebrae. Spinal fractures may be strengthened with cement, screws and nails.”
Complications of back surgery worldwide may reach as high as five percent.
Barzilai recalled a 79-year-old woman with metastasizing cancer who suffered from intense back pain; despite her condition, surgeons managed to help her live two more years painlessly.
“Robotic navigation reduces the risk of paralysis, as it is more exact. We try to reduce the risks by using surgical robots that assist, but they do not replace the surgeons.”
Knee clinic head Dr. Amir Rubin concluded that “there is no pain without inflammation.
Cartilage may be eroded, causing bones to rub together. Most people don’t know they suffer from such erosion, which causes oversensitivity.”
But surgery is often not the answer.
“Exercise is our prescription, not recommendation.
Physical activity is the magic pill for continued pain, as it naturally reduces inflammation. You don’t have to run the marathon, but anybody can do physical activity to suit the problem. The number-one treatment I recommend is to walk, but they can also use a stationary bike or elliptical machine; the third-best is swimming. If you have pains while walking, use Nordic walking sticks. The hospital organizes for Nordic walking. Keep going only until it hurts, but not longer. A warmup,” he advised, is best to ease inflammation. “Wet heat like in a sauna is also very helpful,” he concluded.