Occupational Therapy in Orthopaedics and Trauma E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
This book fills a gap in providing specialist information on orthopaedics and trauma occupational therapy. Its contributors bring together information on the aetiology, surgical input and the occupational therapy intervention appropriate to this client group. It is divided into two main sections, the first being orthopaedics and the second orthopaedic trauma. The first part is further subdivided to cover lower limb surgery, upper limb surgery, spinal conditions, and paediatric orthopaedic conditions. In Part two, principles of fracture management are covered, followed by pelvic and acetabular reconstruction, hand injuries and traumatic amputation.
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Veröffentlichungsjahr: 2013
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Contents
Contributors
Foreword
Preface
Acknowledgements
PART I ORTHOPAEDICS
1. Principles of orthopaedic surgery
Introduction
History and early development
Prevention of infection
Definitions
Prevention strategies
Main conditions, diagnosis and treatment principles
Surgical approaches to symptomatic joint disease
References
Further reading
2. Orthopaedic surgery for the lower limb
Total hip replacement
Total knee replacement
Common conditions of the foot and ankle
Summary
References
Further reading
3. Occupational therapy following elective lower limb surgery
Current practice
The nature of intervention – theory to guide practice
Functional implications for common elective surgical procedures
Total hip replacement/revision total hip replacement
Domestic activities
Total knee replacement
Girdlestone’s excision arthroplasty
Joint fusion
Pathways of care
Assessment
Standardised assessment tools
Postoperative intervention
Outcome measurement
Summary
References
4. Orthopaedic surgery for the upper limb
Introduction
The shoulder
The elbow
The wrist
The hand
The shoulder – main conditions, diagnosis and treatment
The elbow – main conditions, diagnosis and treatment
Tennis and golfer’s elbow
The wrist – main conditions, diagnosis and treatment
Peripheral nerve compression syndromes in the upper limb
The hand – main conditions, diagnosis and treatment
Summary
Further reading
5. Occupational therapy following elective upper limb surgery
Introduction
Preoperative assessment for shoulder and elbow surgery
Rehabilitation of the shoulder
Shoulder arthroplasty
Other shoulder conditions and procedures
Instability
The elbow
Other elbow procedures
Summary
References
Further reading
6. Spinal conditions: management and occupational therapy
Introduction
What are we aiming for?
Degenerative disorders of the spine
Education
Other conditions that may benefit from rehabilitative or management approaches
Summary
References
7. Paediatric orthopaedic surgery
Introduction
Conditions that manifest themselves in childhood
Conditions that some individuals may be prone to
Conditions that may develop during the growing years, after birth
The role of functional assessment
Summary
Further reading
Useful web addresses
8. Occupational therapy for children and young people with orthopaedic conditions
Introduction
Occupational therapy and children and young people with orthopaedic conditions
Summary of key roles, skills and objectives
Assessment and interventions
Preoperative assessment
Postoperative assessment
Child development
Team working and discharge planning
Specialist equipment
Children with developmental dysplasia of the hip
Cerebral palsy
Perthes’ disease
Scoliosis
Leg length discrepancy
Rare conditions
Summary
References
Further reading
PART II TRAUMA
9. Principles of fracture management
Introduction
Basic science
Classification of fractures
Basic fracture healing
Non-surgical fracture treatment
Regional injuries
Compartment syndrome
Polytrauma
Summary
References
10. Occupational therapy within orthopaedic trauma
Introduction
Guidance for intervention
Frames of reference
Models of practice
Assessment and treatment within orthopaedic trauma
Needs of the older fracture patient
Summary
References
11. Pelvic and acetabular fractures: management and occupational therapy
Introduction
Incidence
Anatomy of the pelvis and acetabulum
Classification of pelvic injury
Medical management
Complications of pelvic injury
Team work and the person-centred approach
Occupational therapy intervention
Initial interview
Treatment planning
Mobility and transfers
Transfer techniques
Personal care
Home environment
Long-term goals
Summary
References
12. Hand injuries
Introduction
Bone injuries (fractures)
Joint injuries
Ligament injuries
Tendon injuries
Tendon repair
Peripheral nerve injuries
Classification
Digital
Treatment options
Skin and other soft tissue injuries
Miscellaneous
Chronic regional pain syndrome (CRPS)
Summary
Further reading
13. Occupational therapy for hand injuries
Introduction
Theories informing occupational therapy
Stages of healing
Arches of the hand
Choosing assessment tools
Occupational therapy intervention
Summary
References
14. Brachial plexus injury
Introduction
The brachial plexus
Brachial plexus lesions
Symptoms and diagnosis
Treatment
Complications
Occupational therapy
Flail arm splint
Summary
References
Further reading
15. Traumatic amputation: management and occupational therapy
Introduction
Causes of amputation
Levels of amputation
The multi-disciplinary team
Perioperative intervention
Psychological aspects of amputation
Phantom limb sensation/pain
Lower limb amputee rehabilitation
Rehabilitation of the upper limb amputee
Driving
Support networks
Summary
References
Further reading
Appendix: List of useful organisations
Useful organisations and contacts
Index
This edition first published 2009
2009 John Wiley & Sons Ltd
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Library of Congress Cataloging-in-Publication Data
Occupational therapy in orthopaedics and trauma / edited by Madeleine Mooney, Claire Ireson.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-470-01949-8
1. Occupational therapy. 2. Orthopedics. I. Mooney, Madeleine. II. Ireson, Claire.
[DNLM: 1. Occupational Therapy–methods. 2. Orthopedic Procedures–methods.
3. Wounds and Injuries. WB 555 O1446 2009]RM735.O343 2009615.8′20727–dc22
2009008872
1 2009
Contributors
Daniel Brown, MB ChB, FRCS (Trauma and Orthopaedics)Consultant Orthopaedic SurgeonRoyal Liverpool and Broadgreen University Hospitals NHS TrustLiverpoolUK
Fiona Carnegie, Dip COTSenior Occupational TherapistAmputee Therapy TeamQueen Mary’s HospitalRoehamptonLondonUK
Neil Davidson, MB ChB MRCSSpecialist RegistrarOrthopaedics and Trauma Mersey RotationRoyal Liverpool and Broadgreen University Hospitals NHS TrustLiverpoolUK
Natalie Evans (nee Schroder), BOccThy (Hons)University of QueenslandHead Occupational Therapist – RehabilitationRoyal Brisbane and Women’s HospitalAustraliaFormerly, Paediatric Occupational TherapistNuffield Orthopaedic Centre NHS TrustOxfordUK
Chris Harris, MB ChB, FRCS (Trauma and Orthopaedics)Orthopaedic SurgeonRoyal Children’s HospitalMelbourneAustralia
Heather McDowell, BSc (Hons) OccThy, Certificate in Management (Open)Head of TherapiesRoyal National Orthopaedic Hospital NHS TrustStanmoreMiddlesexUKandChair of the College of Occupational Therapists:Specialist Section in Trauma and Orthopaedics(2008 – present)
Dawn Miller, Dip COTOccupational Therapy Professional LeadWorthing Wheelchair ServiceWest Sussex Primary Care TrustWorthingWest SussexUKFormerly, Head Occupational TherapistOrthopaedics and TraumaSt George’s Hospital NHS TrustTootingLondonUK
Alis Moores, MSc Advanced Health Care Practice, BHSc (Hons) OccThy, Post Graduate Certificate in Academic PracticeSenior Lecturer and Teaching FellowYork St John UniversityYorkUK
Neil M. Orpen, MB ChB, FRCS Ed (Trauma and Orthopaedics)University of StellanboschSouth Africa andSpinal FellowFrenchay HospitalBristolUK
Oliver Pearce, MB BS, MRCS Engl.Specialist Registrar Trauma and OrthopaedicsOxford RotationNuffield Orthopaedic Centre NHS TrustOxfordUK
Kerry Sorby, MSc, Dip COTSenior LecturerYork St John UniversityYorkUK
Julie Upton, Dip COTHead Occupational TherapistNottingham University Hospitals NHS TrustCity CampusNottinghamUKFormerly, Senior Occupational TherapistNottingham Shoulder and Elbow UnitNottingham City HospitalNottinghamUK
Andrew M. Wainwright, MB ChB, BSc (Hons) FRCS (Trauma and Orthopaedics)Consultant Children’s Orthopaedic SurgeonNuffield Orthopaedic Centre NHS TrustandHonorary Senior LecturerUniversity of OxfordOxfordUK
Foreword
Occupational therapy has played a key and well-established role in the lives of people with disabling or potentially disabling conditions for a number of years. Currently health care practices are being revolutionised with, for example, the use of keyhole and robotic surgery and the reduction in lengths of hospital stay, so occupational therapy, like all other health care professions, is rapidly changing too.
The pressures of working in today’s demanding health care environment mean that occupational therapists new to the field of orthopaedics and trauma need quick access to up-to-date and trusted information. This includes the aetiology and current treatment techniques of the most common musculoskeletal conditions matched with evidence based occupational therapy. The aims are as always, to ensure that patients achieve the maximum benefits from surgery and have safe and effective hospital discharges as well as to enable them to maintain independence and quality of life in their own terms.
This book has been compiled with the needs of a busy practitioner in mind. The editors, Madeleine Mooney and Claire Ireson, are both highly respected and experienced specialists in the field of orthopaedics and trauma. They have drawn on their years of experience and the knowledge and best practice of eminent surgical colleagues and other specialist occupational therapists to create a book that can be studied in depth or dipped into for reference.
Spanning assessment, short-term and long-term rehabilitation, together with inpatient and outpatient care, this book has something to offer everyone. Students and occupational therapists returning to work, junior occupational therapists new to orthopaedics and trauma who need to ‘hit the ground running’, rehabilitation assistants and other members of the rehabilitation team working in hospital or in the community, will all find this text an invaluable resource. Although written in the UK, its application is international.
I congratulate Madeleine and Claire for their excellent editing skills and all the authors for their expert and highly readable contributions and I heartily recommend this much needed addition to the occupational therapy literature.
Ann E Stead OBE, MA, DipCOT, SROT
Consultant in Health, Social Care and Inclusion
Formerly, Director of Disability Services at the Nuffield Orthopaedic Centre NHS
Trust, Oxford, UK (1992–2002)
and
Chairman of the Boards of RADAR – the UK Disability Network (2001–2005) and the DARE Foundation (2001–2004)
Preface
In our respective roles as a senior occupational therapist working in a trauma unit within an acute general hospital, and head of occupational therapy services within a specialist orthopaedic centre, colleagues, staff and students regularly questioned us regarding occupational therapy practice within these musculoskeletal settings.
These clinical enquiries were usually received from newly qualified occupational therapists embarking on their first post. This was often within a mixed speciality rotation and these practitioners wished to develop their orthopaedic and trauma skills and knowledge. It was evident that many had not had the opportunity to obtain clinical experience in these areas during their clinical placements when training. Pre-registration occupational therapy students undertaking their practice placement education within a trauma or orthopaedic service were also seeking practical and evidence based knowledge to support their learning in the clinical environment.
Also, as leading committee officers (chair and secretary) of the College of Occupational Therapists Specialist Section: Trauma and Orthopaedics (UK), we received many national and international musculoskeletal occupational therapy practice enquiries. These not only included students and junior occupational therapists, but also practitioners who had recently changed their field of practice, commenced working in new and emerging services providing continuity of care for people with musculoskeletal conditions with which they had limited or out-of-date experience and knowledge or for those who rarely encountered an individual with a musculoskeletal condition in their caseload.
Throughout our collaborative working, while providing support, information and guidance to these practitioners, we became very aware that a well-recognised, practical and evidenced based text, specifically written for occupational therapists working in the field of trauma and orthopaedics was not available to support learning. There are a number of excellent well known orthopaedic textbooks and separate occupational therapy practice texts, but none of these are combined to give easy and quick access to information for busy practitioners.
We were approached to consider producing such a text by Colin Whurr, (then Whurr Publications), who wished to add to the range of occupational therapy publications. Following discussion, we were encouraged and persuaded to embark upon the task. Writing for publication was a new venture for both of us, but proved to be an irresistible challenge. Our agreed scope for the book was to cover the conditions, treatment and management of people with trauma and orthopaedic conditions most commonly encountered by occupational therapy practitioners. We acknowledged that we were by no means experts in all these fields and therefore we agreed we would approach specialist and expert contributors from both occupational therapy and surgical practice to help develop the content of the book.
For ease of reference, the book is divided into two parts: orthopaedics and trauma, with chapters linking the anatomy, aetiology and medical and surgical management of the condition, followed by the application of occupational therapy theory and practice. The chapters describe the most common musculoskeletal conditions and trauma that occupational therapists encounter in their daily practice. With over 200 musculoskeletal conditions affecting millions of people worldwide, there are many more conditions, syndromes and injuries that occur that we are not able to cover here. More information regarding these can be located in the classic orthopaedic texts, via specialist websites and interactive media (some of which are listed at the end of the book).
We have described the theory of occupational therapy intervention and processes, and have presented practical treatment media that is evidence based, and those that are considered best practice by our expert occupational therapy colleagues. We have suggested frames of reference or models of practice and treatment approaches and interventions that are appropriate in this area of practice.
The text has been written to ensure it is appropriate for a wide international readership. Therefore reference to country specific guidelines and legislation has been avoided in most cases. We therefore encourage readers to review their own government, health and professional bodies’ guidelines, legislation and policies and adopt these within their service development and clinical practice. We also acknowledge that access to resources and services will also range tremendously from region to region and from country to country, therefore we have tried to avoid being prescriptive or too specific in terms of recommending equipment or services. We believe our book is unique, and that it demonstrates collaboration and an inter-professional approach to sharing expert knowledge regarding the management of people with musculoskeletal conditions.
The fields of orthopaedics and trauma are constantly developing and evolving as advances in medicine, surgery and technology are made. Occupational therapy practitioners will need to ensure that they remain up to date and that their practice continues to develop and adapt so they remain flexible and innovative in the skills and approaches to the problems people referred to them may face resulting from trauma or musculoskeletal disease. It is certain that the population will continue to be affected by musculoskeletal conditions that limit functional ability and capacity, and that those with functional impairment will continue to need and benefit from the skills and interventions of occupational therapists in the future.
Occupational therapists must ensure that they continue to meet the challenge of being an inter-disciplinary team member who remains focused on the individual’s psycho-social needs, and impact of disease or trauma on their occupations, rather than narrowing their interventions solely on the management of a specific joint or injury. We will see throughout the text that occupational therapists offer a unique and holistic approach to the management of people, ranging from those with acute trauma to those living with a long-term musculoskeletal condition.
We have both learnt many new skills and acquired new knowledge during our editing and publishing journey. We are delighted that Occupational Therapy in Orthopaedics and Trauma has brought together contemporary talents in this field and hope that our book will become the definitive and indispensable text that enhances and develops the reader’s knowledge. Our aspiration is that the reader will be inspired to continue and learn more about this challenging but satisfying area of clinical practice. Ultimately, we anticipate that this will lead to additional reading, study and investigation, thus contributing and expanding the body of research and knowledge base to inform future occupational therapy practice. This will ensure that best practice that is reliable and valid is disseminated. In turn, this will assist in providing the best quality of occupational therapy intervention for people in our care.
Madeleine Mooney and Claire Ireson
Acknowledgements
The editors would like to extend their appreciation to the many friends and colleagues who have helped and supported them in putting this book together.
In particular we are extremely grateful to all our contributors, we appreciate the time and effort you have put into your chapters, while working in demanding jobs, studying for examinations and striving to achieve a healthy work–life balance.
We are also indebted to those of you who read and provided constructive comments on individual chapters, in particular, Dr Chris Mayers for her helpful comments which guided revision of Chapter 3, Badri Narayan for his advice and guidance on Chapter 9 and Fiona Cashin for her thoughts and comments on Chapter 13.
We would also like to thank those of you who have supplied our contributors with photographs and X-rays, including Harry Brownlow, Peter Burge, Sulfi Rahimtula, and Nicola Orpen.
Our gratitude also goes to Philip Hall for his illustrations in Chapters 4 and 11 and Figures 5.1 and 5.2, from originals by T. J. C. Upton. We would also like to thank him for his computer ‘know how’ and invaluable assistance with the photographs throughout the book.
We also acknowledge the kind permission of Emis and Pip 2005 and Elsevier Publications for their kind permission to reproduce photographs, figures and tables, respectively.
Finally, to the publishing staff who have helped and supported us along the way, in particular, Colin Whurr for his enthusiasm in getting us started and to the many staff at Wiley Blackwell, in particular to Emma Hatfield and Catriona Dixon, who have helped us complete the journey.
Part I
Orthopaedics
Chapter 1
Principles of orthopaedic surgery
Neil M. Orpen
Introduction
In this chapter we will explore some of the more recent developments in orthopaedic surgery, in particular, those aspects that form the basis of everyday practice. In recent years there has been a rapid expansion in the treatment options available to people with musculoskeletal disease. This has resulted from the development of safe anaesthesia, improved engineering of implant materials and refinement of surgical techniques. With this improvement, a greater emphasis has been placed on the person’s recovery from surgery which, in turn, has led to the development and importance of rehabilitation and the multi-disciplinary approach to people’s care.
History and early development
Orthopaedics derives from the Greek words ‘straight’ and ‘child’ and was a term described by Nicholas Andry (1658–1759) in his book Orthopaedia: or the Art of Correcting and Preventing Deformity. Much of the early practice of orthopaedics was concerned with the correction of deformity. More recently, as our population age has changed, the conditions that form part of our everyday practice have changed too. To mention all the important developments in the process of orthopaedic history would be exhausting, but some names of interest follow.
Ambroise Pare (1510–1590) was a prominent surgeon in France in the sixteenth century and published on anatomy and physiology and later on surgery. He described a number of surgical techniques relating to amputation such as the use of ligatures for large vessels, and tourniquets. He also designed a number of surgical instruments and artificial limbs. At times of conflict, limb amputations were common and often the only treatment for limb injury and deformity. Limb amputation skills were displayed with amazing speed and precision in experienced hands.
Antonius Mathysen (1805–1878) invented the plaster of Paris (POP) bandage which remains part of everyday orthopaedic and trauma practice. Little has changed in the principle of this form of splintage since its creation and only some of the indications have been altered to keep up with alternatives offered by surgery. Joseph Lister (1827–1912) became James Syme’s (of Syme amputation fame 1942) house surgeon and later married his daughter. While working as assistant surgeon to the Royal Infirmary in England he introduced antisepsis, which had a dramatic effect in reducing infection, and infection related mortality. This paved the way for further developments in surgical techniques and is a crucial part of successful surgery and specifically to orthopaedic surgery today. Wilhelm Conrad Rontgen (1845–1923) was a professor of Physics at Wurzburg and discovered roentgen rays (X-rays). The first radiograph taken was of his wife’s hand and this was allegedly offered to her as a Christmas present. Something he may not get away with today! In 1901 he received the Nobel prize for his work in this area.
Gathorne Robert Girdlestone (1881–1923) was the first professor of orthopaedics in Britain and has a long association with a number of prominent centres, including the Nuffield Orthopaedic Centre in Oxford. His technique of excision arthroplasty of the femoral head is a procedure now used mainly as a salvage procedure after failed hip replacement and carries his name. Originally it was commonly used to treat hip tuberculosis prior to the advent of antibiotic therapy and joint replacement surgery. In 1942, an American, Austin Moore (1899–1963), performed and reported the first metallic hip replacement. Although it involved replacing the entire upper portion of the femur with a vitallium prosthesis, this was the start of a rapid development in better designs and techniques. Sir John Charnley (1911–1982) improved the design of the total hip replacement and was also involved with the development of self-curing acrylic cement. Many of the hip joint arthroplasties performed in the 1960s by him are still surviving well. It is open to debate as to whether his excellent design was luck or brilliance, but it was to form the benchmark for total hip replacements for the next 40 years.
Other centres such as Exeter have now proven results of joint replacement while those such as Birmingham are in the early stages of producing promising long-term results with newer designs. The Birmingham hip resurfacing arthroplasty, designed by Derek McMinn and colleagues at the Royal Orthopaedic Hospital in Birmingham in the early 1990s has had widespread interest due to a successful return to early design principles but now with better manufacturing techniques and better results. Other designs of this metal on metal resurfacing arthroplasty have followed and these types of replacement are now widely used throughout Europe, the USA and Canada.
Although huge strides have been made in the past century in the field of orthopaedics, it is expected that similar ongoing advances will continue to be made. Developments in cartilage replacement options hold promise as alternatives to joint replacement and there is continued development in the field of stem cell research. These and many others offer tremendous therapeutic options for an ever-increasing population of people with orthopaedic problems.
Prevention of infection
Prevention and management of infection in orthopaedic surgery has been one of the most important advances over the past century, which has allowed rapid development in our practice. Over 70% of hospital-acquired infections occur in people who have undergone surgery and these lead to considerable morbidity and rise in surgical costs. Treatment of infection in bone can be very difficult, and following implant surgery even more of a challenge, and so the prevention of infection is where we place a great deal of our efforts.
Definitions
Decontamination
– a process of removing microbial contaminants which can be carried out by cleaning, disinfection or sterilisation.
Cleaning
– a process that removes visible contaminants but does not necessarily destroy microorganisms.
Disinfection
– reduces the number of viable organisms to an acceptable level but may not inactivate some viruses, hardy organisms such as mycobacteria, or spores. A topical disinfectant that can be safely applied to epithelial tissue (like skin) is called an
antiseptic
.
Sterilisation
– this involves complete destruction of all viable microorganisms, including spores, viruses and mycobacteria. This may be accomplished by heat, radiation or chemical means and often the choice depends on the nature of the material being sterilised.
Prevention strategies
Handwashing has been shown to be the single most important method of controlling the transmission of hospital-acquired infection, as organisms are passed from one person to the next via staff caring for them. Washing the hands before and after physical contact with people and after activities where they are likely to become contaminated cannot be overemphasised.
Soaps, detergents or alcohol-based agents are now commonly provided in areas such as wards, clinics and outpatient departments where staff come into direct contact with people. A set of ‘universal precautions’ are typically taught and are available as a way of reminding staff of ways to prevent the transmission of infection. These include instructions on wearing gloves, dealing with wounds, sharp instruments and contaminated products. All staff should make themselves familiar with local policies and guidelines relating to these.
Screening of at-risk patient groups is important especially in the more controlled environment of planned or elective surgery. Organisms that can be detected and controlled, such as methicillin-resistant Staphylococcus aureus (MRSA), are important to detect prior to high-risk surgery and particularly in implant surgery. It is advisable to isolate a person found to be carrying these organisms so as to prevent the transmission to other people in the ward.
Antibiotics are used routinely in implant surgery and have been shown to reduce the risk of postoperative wound and deep infection. Broad-spectrum prophylactic antibiotics given prior to starting the surgical procedure are required for implant surgery and the choice of antibiotics is often dependent on local microbiological guidelines. The widespread use of antibiotics in all clinical settings, however, has led to certain organisms becoming resistant to various agents, for example:
MRSA
Vancomycin-intermediate
S. aureus
(VISA)
Vancomycin-resistant
Staphylococcus epidermidis
(VRSE).
The appropriate use of antibiotics, however, is an essential part of prevention of infection in orthopaedic surgery.
Theatre strategies include sterile gowns, drapes, double gloves, and the use of masks and caps. Air-borne bacteria are a source of postoperative sepsis and now laminar-flow ventilation systems in theatres are becoming the norm to supply ultra-filtered air to the operative field and thereby reduce infection. Evidence exists to show that the use of ultra-clean air conditions will reduce the incidence of deep periarticular infections by half (from 3.4% to 1.6%). The addition of antibiotics will further reduce this to 0.19%. This is of particular benefit in prosthetic implant surgery (Lidwell et al. 1987).
All staff in contact with the operative field or instruments involved in surgery are required to disinfect their hands prior to placing sterile gloves on for surgery. This is aimed at reducing the volume of viable organisms, which may otherwise contribute to postoperative infection. A number of preparations are available, and many are alcohol or iodine based.
The surgical area is prepared with an antiseptic solution and care is taken that nothing contaminates this during surgery. Sterile drapes are used and all instruments used are sterilised to ensure no viable organisms are likely to contaminate the operative field.
Main conditions, diagnosis and treatment principles
Osteoarthritis
Osteoarthritis is a non-inflammatory degenerative joint disease. It is characterised by loss of articular cartilage and associated with new bone formation and capsular fibrosis that results when chondrocytes fail to repair damaged cartilage. The causes fit into two broad groups:
Primary/idiopathic
– no obvious cause
Secondary
– identifiable cause:
Typically this condition is progressive and results in pain and stiffness in the joint involved. This may lead to:
Alteration of limb length
Fixed deformity in the joint limiting movement
Progressive wasting of muscles as the limb is used less.
People who experience symptoms and signs of non-inflammatory arthritis have the clinical diagnosis confirmed with X-rays. Radiological signs include (Figure 1.1):
Figure 1.1 Radiological signs of osteoarthritis.
Joint space narrowing – initially at maximal load area before progressing to the entire joint
Development of osteophytes as the joint endeavours to repair itself
Subcortical/ subchondral sclerosis indicated by thickening of the bone below the joint surface
Subchondral pseudo-cyst formation.
Initially treatment should always involve conservative/non-operative options. Once non-operative measures have been exhausted, surgery may be considered. The non-operative/ conservative measures recommended are:
Protection of joint overload by achieving weight loss and using walking aids
Exercise of supporting muscles to avoid wasting and prevent stiffness
Pain relief in the form of analgesics and anti-inflammatory drugs
Intra-articular corticosteroid injections
Intra-articular hyaluronic acid injections (Snibbe and Gambardella 2005)
Glucosamine and chondroitin (Richy et al. 2003).
Operative measures (for people with persistent pain and symptoms despite conservative measures) include:
Arthroplasty – unicompartmental or total joint arthroplasty
Realignment osteotomies in younger persons.
Some treatments are being used but do not yet have convincing evidence to prove their benefit and at this stage should be considered experimental. For example, soft tissue grafts, such as:
Chondrocyte transplants (Bentley et al. 2003)
Mosaicplasty (Bentley et al. 2003)
Fresh osteochondral grafts (Ma et al. 2004)
As this condition is such a large part of everyday practice in orthopaedics, it is also part of massive financial investment into newer forms of treatment, many of which do not have good evidence to prove their benefit. These do form an essential part of the on-going development of our practice but must be used in controlled environments and with caution.
Rheumatoid arthritis
Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease with an unclear aetiology and a number of joint sequelae. The symptoms are that of an inflammatory arthritis and typically the person experiences acute or chronic episodes throughout their life. Much of the treatment is aimed at controlling the condition and preventing the chronic changes usually associated with RA. Early aggressive medical treatment can control the condition and limit joint damage and thus prevent or limit the chronic disability typically associated with rheumatoid arthritis in the past.
Usually RA progresses through three stages:
Rheumatoid joint disease
Symptoms should be considered as either systemic or local to the joint. They are typically symmetrical and can affect any joint, although most commonly begin in the smaller joints of the fingers, hands, and wrists. People with RA are more susceptible to infection. Systemic symptoms include:
Fatigue
Early morning stiffness or stiffness after rest
Flu-like symptoms
Rest pain
Flares in symptoms followed by disease inactivity
Rheumatoid nodules (occur in one-fifth of patients)
Loss of appetite, anaemia, weight loss
Sjögren’s syndrome – involvement of the glands around the eyes and mouth causes decreased production of tears and saliva.
Diagnosis of RA is based on a collection of information rather that one specific test. This includes the person’s history, clinical examination, laboratory tests and radiological investigations; specific criteria must be met before a diagnosis is made. Current treatment methods focus on relieving pain, reducing inflammation, slowing or preventing joint damage, and improving function. Medication/therapeutic categories are based on those that are aimed at controlling the progression of disease and those aimed at symptomatic relief.
Non-steroidal anti-inflammatory drugs (NSAIDs)
– reduce inflammation, pain and fever. A side effect is an increase in bruising and bleeding and care should be taken when handling patients with RA.
Analgesic drugs
– relieve pain.
Corticosteroids
– low doses to reduce inflammation and to prevent joint damage. These may be administered systemically or as local intra-articular injections. Oral steroids should never be stopped abruptly.
Disease-modifying anti-rheumatic drugs (DMARD’s)
– used in combination with other drugs to slow joint destruction over time, e.g. methotrexate, penicillamine, azathioprine. Care needs to be taken due to known side effects and drug interactions.
Immunotherapies
– such as anti-tumour necrosis factor (TNF) drugs. These are biological agents and immunoactive drugs, which principally inhibit cytokines in the immune system to control inflammation. There are no long-term studies that have looked at the effects of these on disease outcome.
Alternative therapies
– many people may have been given advice, or may have done their own research, on alternative therapy strategies. Although there may not be good evidence to support many of these, an open mind should be kept regarding those which people choose to take. Medical practitioners should be careful not to advise on therapies unless they are knowledgeable or trained in this field.
We now know that combination therapy is usually most effective in controlling the disease and therefore a person will usually be on more than one form of medication. However, despite medication and orthoses, many people will eventually require some form of surgery and techniques often used are:
Synovectomy
– to reduce the amount of inflammatory synovium in the joint. This can usually be performed arthroscopically or as keyhole surgery in the knee, but as an open procedure in other joints. Imminent tendon rupture in the hands is best treated with early synovectomy rather than later reconstruction (Gibbons et al. 2002; Ryu et al. 1998).
Joint replacement/arthroplasty
is used when pain is not controlled by medication alone and a person is limited in their movement. Typically partial replacement of joint (e.g. unicompartmental knee replacement or hemiarthroplasty of the hip) is not suitable as the whole joint is involved in rheumatoid arthritis.
Arthrodesis/fusion
can be used to control pain although it does prevent movement in the joint. This is more commonly employed in the foot and ankle.
Osteomyelitis
Osteomyelitis is an acute or chronic infection of the bone, which is usually caused by bacteria. In children the source of infection is typically via the blood (haematogenous) from another site in the body in the form of a bacteraemia or septicaemia whereas in adults the source is usually exogenous (e.g. after trauma or surgical intervention). Risk factors for development of osteomyelitis include:
Local trauma, such as open fractures
Previous orthopaedic surgery
Diabetes mellitus
Immunosuppression, such as in RA, chronic steroid therapy, human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) or chronic illness
Drug misuse
Malnutrition.
In children, the presentation is early and symptoms typically occur before radiological signs. Haematogenous spread may occur to any bone but the vertebral bodies are the most commonly affected. Symptoms and signs of acute osteomyelitis include:
Systemic
Local
History taking and examination should elicit the symptoms and signs and the diagnosis can be confirmed by further special laboratory and radiological investigations.
Laboratory investigations are aimed at evaluating the systemic response to infection and include full blood counts, C-reactive protein levels (CRP), and erythrocyte sedimentation rate (ESR). Blood cultures may offer a microbiological diagnosis prior to commencing antibiotic treatment and are positive in up to 50% of people tested. These may also be used to monitor the response to treatment.
Radiological investigations include radiographs of the affected bone although in acute infection there may be a delay in radiographic appearances of up to ten days. Ultrasound may be useful in the early stages in children with increased fluid in an affected joint and periosteal lift-off from an affected bone. Magnetic resonance imaging (MRI) (almost 100% sensitive) and computed tomography (CT) can be used to provide additional information regarding the diagnosis and extent of spread; these investigations can also aid in aspiration procedures to gain a microbiological diagnosis prior to commencing antibiotic therapy. Two conditions, which may often feature in the differential diagnosis are malignancy and tuberculosis (TB) and should always be considered, especially if the history is not typical. Although TB is uncommon in developed countries its incidence is increasing with increases in population migration and immunosuppressive illnesses such as HIV.
Treatment strategies are aimed at either suppression or eradication of the infection. One of the difficulties in dealing with bone infection is that penetration of antibiotics into bone is often limited and the environment of dead tissue further inhibits antibiotic penetration and activity. Bacteria can then live for prolonged periods causing recurrence of infection years after the initial infection is treated.
Eradication therapy may involve a combination of prolonged antibiotic therapy, together with surgical debridement. Debridement implies the removal of all dead material from the infection site as well as any foreign material (such as joint replacements). When involvement is extensive, surgery may result in large areas of bone loss, which will require further surgical correction when the infection is eradicated.
Septic arthritis
Joint infection is an important but less common cause of acute joint pain and is of vital importance to diagnose and treat early. A delay in the diagnosis can lead to rapid irreversible joint destruction and therefore treatment should be considered a surgical emergency. It is most common in the larger joints, and particularly in the adult it is often seen in the hand joints following hand trauma and in the foot in conditions such as diabetes mellitus. The clinical features in the infant are considerably different from those in adults, but here we will consider them together.
Symptoms and signs include:
Children:
Adults
Look for septic focus or history of recent illness.
In a child a high index of suspicion is required so as not to miss the diagnosis, whereas in the adult a clear history may steer one onto the correct path to a good clinical examination and then special investigations. Laboratory investigations are similar to those used to diagnose acute osteomyelitis but joint aspiration is essential to acquiring a microbiological diagnosis before starting antibiotic treatment. Aspiration of the knee is easy to perform in the clinic setting. As access to the hip is more difficult, the assistance of a radiologist may be required as an ultrasound-guided aspiration may be useful. This is particularly the case in a child, whereas in the adult this may simply be done under X-ray guidance.
Establishing the diagnosis early is crucial as the differential diagnosis may include much less serious conditions:
Trauma
Acute osteomyelitis
Rheumatic fever
Transient synovitis
Gout
Acute rheumatoid flare.
The treatment of this condition should always include a washout and antibiotics. The antibiotic course may be prolonged. When septic arthritis is complicating a joint replacement or other surgery involving a prosthesis or metal work, it may only be possible to clear the infection by removing the metal component.
Avascular necrosis
Avascular necrosis (AVN)/osteonecrosis/aseptic bone necrosis refers to a condition of bone cell death following loss of the blood supply. Although potential causes are multiple and in 25% not clearly defined, they more commonly include:
Trauma
Joint dislocation
Steroid use
Perthes’ disease
Fractures
Heavy alcohol use
Deep sea diving (Caison’s disease) (Kenzora and Glimcher 1985).
Very often the true pathogenesis is unclear but the result is ischaemia at a cellular level followed by cell death and then a period of attempted repair, which may take place to varying degrees. Diagnosis can be difficult and early radiological features may be indistinguishable from other conditions. X-rays are therefore often of limited use. The advent of MRI has made the diagnosis much easier and features on MRI scan are typically present much earlier in the disease process.
Treatment is generally aimed at either helping the bone to repair itself or protecting the affected bone while the remodelling process occurs. When the diagnosis is made late or the remodelling process is inadequate, additional procedures may be required, aimed at reducing the pain in associated degenerated joints. This may take the form of fusion procedures, realignment operations or joint replacements and often depends on the joint affected and the age of the patient.
Bone grafting
Bone grafting involves the implantation of bone into an area of the skeleton for a specific surgical need. The sources of bone graft and surgical situations are mentioned in the list below but ultimately the aim is to encourage new bone formation.
Definitions
Autograft
– tissue grafted from one part of the body in the same individual to another part of the body in that individual (e.g. bone from the hip placed in the femur).
Isograft
– graft taken from a donor who is genetically identical to the recipient (tissue from one identical twin to another).
Allograft/homograft
– a graft of tissue from one individual to another of the same species with a different genotype (i.e. not from an identical twin).
Xenograft
– a graft of tissue taken from one species to a different species such as from a pig to a human.
There are a number of situations where bone grafting may be useful in orthopaedic and trauma surgery:
Bone loss following trauma, infection, previous surgery where a space needs to be filled
Delayed union/non-union of fractures, where bone with its various bone morphogenic proteins (BMPs) can be introduced into the site of poor healing to stimulate the formation of new bone
Structural support in a bone defect such as revision joint replacement or a depressed articular surface in tibial plateau fractures
Large bone defects where a large element of the bone is missing and another bone is harvested to bridge the defect/provide support and take over the function of the missing bone (bone tumours resulting in a large resection of bone such as vascularised fibular grafting following femoral resection for osteosarcoma)
Encourage bone formation in arthrodesis/fusion surgery.
Most commonly autograft, and then specially prepared allograft, is used as this provides the least possible risk of tissue rejection. When only small amounts of bone are required, this can be harvested from the patients themselves with ease. This has the benefit of providing living tissue with all the bone stimulating factors that come with it. The iliac crest, distal femur, distal radius and fibula are commonly sources of donor bone tissue. Bone grafting is not without complications, however, and the risk of pain, nerve injury and infection are some of the things that must be taken into account when considering this procedure. This has led to research into newer bone substitutes being developed. Many of these are used purely for the structural element but some have the addition of bone stimulating proteins and other substances to encourage bone formation and therefore the additional benefits usually only provided with autograft.
Bone tumours
By far the most common tumour found in bone is that of a secondary deposit from a primary tumour elsewhere in the body. Typically malignant spread from lung, breast, kidney, prostate and thyroid occurs to bone but more uncommon metastatic tumours and haematological malignancies may also be found. We will mainly deal with primary bone tumours in the following text but for detail on specific tumours, the reader is referred to the recommended reading at the end of the chapter. Bone tumours are classified as follows:
Benign:
Malignant – primary:
Malignant – secondary
People typically present with pain, which may occur with movement but also occurs with rest and at night. They may develop swelling and reduction of muscle bulk as the limb is used less. Systemic features of a tumour may exist, such as weight loss, anaemia, lymph node swelling, malaise, or those symptoms related to the primary elsewhere in the body. Temperature and sweating may suggest Ewing’s sarcoma, but, of course, are also part of the clinical spectrum of infection and thus form part of the differential diagnosis. It is not unusual for the history to relate to a particular sporting or trivial injury and this risks a delay in diagnosis as health professionals, while treating it as a minor sporting or musculoskeletal injury, follow a conservative approach. (Musculo et al. 2003).
The first presentation may be of a pathological fracture or it may even be a coincidental finding. Following a good history and clinical examination some special investigations will offer further assistance in clarifying the diagnosis. Radiographs of the affected limb are mandatory and if concern is raised that a tumour is present then a chest radiograph should also routinely be requested. Tumours may be bone forming or bone destroying in nature. Further screening blood tests are aimed at diagnosis of the specific lesion and also to search for other causes, bearing in mind that bacterial osteomyelitis and TB infection should always form part of the differential diagnosis. Full blood counts, ESR, CRP and biochemical profiles are routine. If one is considering prostate carcinoma in men, then a prostate specific antigen (PSA) level is necessary and in older people being screened for myeloma, protein electrophoresis is requested. In searching for a primary tumour, a CT scan of the bone and other body regions can be useful and an MRI can determine the extent of the lesion within the bone. MRI is also the study of choice for soft tissue lesions and when the extent of soft tissue involvement is to be evaluated. Unless the diagnosis is certain, a biopsy is obtained for confirmation of the diagnosis and to assist in staging and planning surgery. When a specialist centre is available, this is best done under the supervision of an experienced surgeon or radiologist. Staging of tumours is necessary to determine the prognosis. The various prognostic factors used to define tumour stage include:
Location and relative size
The presence or absence of regional or distant metastases
The histologic grade of the tumour.
Good histopathological and microbiological expertise is vital. In children cytogenetic samples can be useful and this requires the necessary backup to be available. Once staging is complete, a treatment plan can be devised and this is specific for the tumour type.
The three modalities available to treat bone tumours are chemotherapy, radiotherapy and surgery. The tumour variety will dictate the regimen and timing of surgery. Osteosarcoma for instance responds to chemotherapy which is offered prior to surgery and again following excision whereas chondrosarcomas do not respond to chemo- or radiotherapy and complete excision is the treatment offered. Ewing’s on the other hand is treated by a combination of chemotherapy and surgical resection and if the response is incomplete it is treated with radiotherapy. Following surgical resection of a tumour, consideration must be given to reconstruction if necessary. Excision also often involves an envelope of soft tissue (muscles, tendons, etc.) which is important in ensuring a good prognosis and minimising recurrence; this will also be important in the reconstructive options available (Les et al. 2001). Endoprostheses, vascularised fibula grafts, bone grafts in combination with muscle flaps are options and good plastic surgical backup is often a prerequisite to satisfactory treatment. When the tumour is a secondary deposit, the aim of surgery in these circumstances is to improve the person’s function to as near to normal as possible, to control pain and the treatment or prevention of pathological fractures. Plates and screws are seldom adequate as the bone is not expected to heal and therefore bridging of the diseased part of the bone with an intramedullary device is often required. A number of other devices are available and the best option depends on the specific site and tumour being treated. The life expectancy of a person presenting with a secondary metastatic lesion to the bone is 12 months in the UK but this is worse in people with lung metastasis and much better in carcinoma of the breast and kidney.
Nerve injury
Nerve injury is a common presentation of trauma but unfortunately is also a realistic risk following a number of therapeutic interventions and surgical procedures. In trauma the risk of an associated neurological injury increases in open injuries but even in closed injuries may occur at the time of injury or later from conditions such as compartment syndrome.
Aetiology of nerve injury may include:
Trauma
Metabolic
Malignancy
Toxins
Thermal
Infection
Scarring
Callus in fractures
Ischaemia
Arteriovenous malformations.
Some terms to be familiar with, which provide a useful classification, are as follows.
Neuropraxia
– this is a physiological interruption in function in a nerve that is anatomically intact. The axons remain intact but conduction stops because of segmental demyelination. The lesion is transient and full spontaneous recovery is expected within weeks to months.
Axonotmesis
– in this lesion the axons are separated and this results in the distal end of the axon degenerating by a process called Wallerian degeneration. Because the myelin sheath remains intact, the nerve regenerates along the previous path and recovery is likely, although slow. Sensory recovery is better than motor.
Neurotmesis
– this is complete transaction (by neurotmesis) of the nerve such as would occur in a surgical transection. There is a limited ability for nerve regeneration in peripheral nerves if the two cut ends are brought into apposition as would occur with surgical repair. Even after a good repair, only partial recovery can be expected.
Following an injury, the nerve goes through four pathological phases:
Retraction
Inflammation
Degeneration –
retrograde
(primary) to the next proximal node of Ranvier but histologically the same as Wallerian;
Wallerian
(secondary) distal to point of injury
Regeneration.
Diagnosis requires a good knowledge of the nerve anatomy and testing of the motor, sensory, and autonomic function of the nerve involved, bearing in mind that different signs are present during the various stages of the nerve injury process.
Although a good history and clinical examination may provide most of the information necessary to determine the type of injury present, when there is doubt, further information may be provided by neurophysiological studies. These are best performed two to three weeks after injury to distinguish a neuropraxia from an axonotmesis/ neurotmesis. This therefore may provide useful information on the extent of the lesion and also the prognosis but prior to this has a limited role. Usually neurophysiological testing is reserved for those injuries which at six to eight weeks are not showing the recovery that was expected. MRI investigation of nerves is currently a research tool. Surgical exploration early in the course of a lesion may however be of more use, in that a conclusive diagnosis will be provided and repair may be undertaken at the same time. This is particularly true in trauma where neurotmesis is more likely and in this situation early repair is likely to be easiest and provide a better long-term result. When there is a delay to surgery, retraction often makes primary repair impossible and nerve autografts are considered. This of course means loss of a nerve elsewhere and also is not always as successful as could be expected if the repair was performed early.
Following repair it may be necessary to protect the soft tissues and the repair, and splinting may be required. This may also be necessary for the associated injuries and much of the treatment relies on good rehabilitation support while recovery occurs. When repair of the nerve is not achievable the emphasis may shift to tendon transfers to improve joint movement and prevent contractures or procedures directly aimed at the control of pain secondary to nerve injury.
Surgical approaches to symptomatic joint disease
Joint disease forms a prominent part of general orthopaedic practice and as the population ages this becomes even more the case. Conditions of the joints are not confined to older people, and this should become clear in the following chapters.
Surgery in the young is very often aimed at preventing the later development of joint degeneration such as in developmental dysplasia of the hips (DDH) and creating mobile painless joints. In older patients, however, surgery is usually reserved for failure of medical control of painful degenerative changes or inflammatory joint disease such as RA. Broadly, procedures are grouped into:
Joint debridement
– this may be aimed at removing inflamed synovium in inflammatory conditions to prevent destructive changes (RA) or removing bony osteophytes (OA), which through impingement may cause pain or impair movement. The true benefit of debridement and joint washout in OA is of some debate. This can usually be performed arthroscopically in larger joints.
Arthrodesis/fusion
– as pain in the joint can be caused by two degenerative surfaces rubbing against one another, fusing the joint prevents any movement and therefore stops pain, and is particularly useful in the small joints of the ankles, feet and hands and in the spine. It can also be used in specific situations in the hips and knees. One must bear in mind, however, that loss of movement in one joint may have an effect on adjacent joints, which may therefore later also require additional procedures.
Joint excision/excision arthroplasty
– This was practised historically in the treatment of infected and degenerate joints, and in the 1940s for the treatment of tuberculosis of the hip. The modern indications include failed infected joint replacement, recurrent dislocation of hip replacement and in specific cases of rheumatoid arthritis where a painful joint may be excised and the joint space filled with soft tissue which will eventually fibrose and thereby reduce and treat pain. The loss of stability and movement need to be considered and this is only suitable when a limited functional demand exists. In the large joints it is generally a salvage procedure and function is usually poor. Girdlestone described an excision arthroplasty of the hip, which bears his name (Horan 2005).
Osteotomy
– an osteotomy is a surgical technique involving a cut through the bone to realign or change the orientation of the axis of the bone. In joint disease this may be useful when trying to offload a particular articular surface such as to realign the joint. The chances of success are greater in younger patients; examples include high tibial osteotomies in unicompartmental arthritis of the knee where joint replacement may be less desirable. Osteotomies, however, can be used in a number of other circumstances and this will be highlighted in other chapters too.
Arthroplasty
– successful joint arthroplasty or replacement is one of the major advances in orthopaedic surgery and forms a prominent part of routine work performed in all units. The replacements are typically manufactured from a combination of metal alloys depending on the metal properties desired such as stainless steel and titanium. These are combined with an articulating component of polyethylene, metal or ceramic; the benefits and disadvantages of each are large discussions on their own. The prosthesis can be cemented or uncemented and design elements are used to ensure a good, firm contact with the bone. A variety of terms are used to indicate which and how much of the joint is removed and replaced (
Figure 1.2
).
Surface replacement
– a modification of a total joint replacement involving only removing the articular cartilage and a minimal amount of subchondral bone. This provides the benefit of making further procedures and revision surgery easier as more bone is preserved. This is a refinement of an early technique made possible by better manufacturing methods in the production of prosthetic materials and articular surfaces. More detail will be provided in individual chapters.
Figure 1.2 From left to right: examples of total hip replacement, surface replacement and hemiarthroplasty of the hip.
Although joint replacement is a prominent part of orthopaedic practice, it is not without risk and these need to be considered carefully. The potential need for revision surgery in the future needs to be considered and in younger patients this may be required on more than one occasion. General risks of joint replacement include:
Infection (1–5%)
Dislocation
Loosening (5%)
Periprosthetic fracture
Future revision
Reduced movement
Persistent pain
Neurovascular injury.
Bearing in mind that none of the surgical options available are without risk, careful consideration should be given to the best option for each individual with the patient and multi-disciplinary team being actively involved in the decision-making process.
References
Bentley, G., Biant, L. C, Carrington, R. W., Akmal, M., Goldberg, A., Williams, A. M., Skinner, J. A., & Pringle, J. (2003). A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. Journal of Bone and Joint Surgery, British Volume, 85, 223–230.
Gibbons, C. E., Gosal, H. S., & Bartlett, J. (2002). Long term results of arthroscopic synovectomy for seropositive rheumatoid arthritis: 6–16 year review. International Orthopaedics, 26(2), 98–100.
Horan, F. T. (2005). Robert Jones, Gathorne Girdlestone and excision arthroplasty of the hip. Journal of Bone and Joint Surgery, British Volume, 7, 104–106.
Kenzora, J. E., & Glimcher, M. J. (1985). Accumulative cell stress: the multifactoral etiology of idiopathic osteonecrosis. Orthopedic Clinics of North America, 16, 669–679.
Les, K. A., Nicholas, R. W., Rougraff, B., Wurtz, D., Vogelzang, N. J., Simon, M. A., & Peabody, T. D. (2001). Local progression after operative treatment of metastatic kidney cancer. Clinical Orthopaedics and Related Research, 390, 206–211.
Lidwell, O. M., Elson, R. A., Lowbury, E. J., Whyte, W, Blowers, R., Stanley, S. J., & Lowe, D. (1987). Ultraclean air and antibiotics for prevention of postoperative infection. A multicentre study of 8052 joint replacement operations. Acta Orthopaedica Scandinavica, 58(6), 4–13.
Ma, H. L., Hung, S. C., Wang, S. T., Chang, M. C., & Chen, T. H. (2004). Osteochondral autografts transfer for post-traumatic osteochondral defect of the knee-2 to 5 years follow-up. Injury, 35, 1286–1292.
Musculo, D. L., Ayerza, M. A., Makino, A., Costa-Paz, M., & Aponte-Tinao, L. A. (2003). Tumours about the knee misdiagnosed as athletic injuries. Journal of Bone and Joint Surgery, American Volume, 85, 1209–1214.
Richy, F., Bruyere, O., Ethgen, O., Cucherat, M., Henrotin, Y., & Reginster, J. Y. (2003). Structural and symptomatic efficacy of glucosamine and chondroitin in knee osteoarthritis: a comprehensive meta-analysis. Archives of Internal Medicine, 163(13), 1514–1522.
Ryu, J., Saito, S., Honda, T., & Yamamoto, K. (1998). Risk factors and prophylactic tenosynovectomy for extensor tendon ruptures in the rheumatoid hand. Journal of Hand Surgery (Edinburgh, Scotland), 23(5), 658–661.
Snibbe, J. C., & Gambardella, R. A. (2005). Treatment options for osteoarthritis. Orthopaedics, 23(2), S215–216.
Further reading
Kirk, R. M., & Ribbans, W. J. (2004). Clinical Surgery in General (4th edition). London: Churchill Livingstone.
Schajowicz, F. (1994). Tumours and Tumour-like Lesions of Bone (2nd edition). Berlin: Springer Verlag.
Vaccaro, A. R. (2005). Orthopaedic Knowledge Update: Home Study Syllabus (8th edition ). USA, Illinois: American Academy of Orthopaedic Surgeons.
Walker, J. M., & Helewa, A. (2004). Physical Rehabilitation in Arthritis (2nd edition). St Louis: W.B. Saunders.
