Not every Orthopaedic condition requires an operation, and there are circumstances when a surgical procedure is not possible. In these instances the Surgeon may have the following modalities of treatment available.
Pharmacological methods – Various drug preparations can be used to treat, or supplement treatment, of an Orthopaedic condition. The most commonly used drugs are those which serve to reduce pain. There are a wide variety of these preparations, which differ in their strengths of ability to reduce pain.
The most commonly used such preparations are the ‘non-steroidal anti-inflammatory’ agents which are often enough to bring about a significant pain relief. Failing this stronger analgesic medication may be required. Morphine based drugs, which include Morphine, Tramadol and Oxycodone, would be a stage up, with the understanding that long term usage can lead to dependence, addiction and tolerance among a number of other side effects and drug interactions
Neuropathic pain, that is pain from an injured nerve, can be particularly uncomfortable and is often treated with drugs including Tegretol and Pregabalin, both of which can have significant side effects.
Steroid injections – Steroid and/or anaesthetic agents injected locally into trigger spots, areas of tendonitis or bursitis, synovial joints such as the knee or hip, and into the spine often bring a rapid relief of pain and allow for an improved motion of the trunk or limb.
These injections are safe and effective in the great majority of cases but are not entirely without their problems. Mild, temporary complications have been recorded, including some increase in pain, headaches, flushing of the face, anxiety, insomnia and fevers, and reaction around the injection sites. They can cause an increase in blood sugar levels which diabetics must be warned about. Multiple injections into the same area can cause increased damage to the affected joint, temporary decrease in immunity, stomach ulcers and cataracts. Very rarely paraplegia or quadriplegia has occurred after an injection into the spine. Because of the possible untoward cumulative effects of the steroid no more than three injections should be done in any one year.
Disease modifying drugs – Generalized musculo-skeletal conditions, such as Rheumatoid arthritis or the so-called ‘collagenoses’ which are allied to it, may be treated with steroid agents or other ‘disease modifying’ drugs in order to reduce the pain and inflammation which they cause in the joints of the body. A number of such ‘disease modifying drugs are available for the treatment of Rheumatoid arthritis viz. azathioprine, gold injections, hydroxychloroquine, methotrexate and sulfasalazine.
Cytotoxic drugs – Tumours and malignancies occasionally affect the musculo-skeletal system. The treatment of these conditions is often surgical but these procedures are generally supplemented by radiotherapy and ‘cytotoxic’ drugs.
Anticoagulants – Thrombosis of the deep veins of the leg is a complication which can occur in association with various forms of Orthopaedic treatment, particularly operative. There are many factors which are associated with its occurrence and some individuals are at greater risk of suffering it than others. Different pharmacological agents are often administered by mouth or by injection in an attempt to prevent it developing or treat it if present. Similarly, physical methods such as compression stockings or intermittent compression of the feet and lower legs are frequently used after surgery to try and prevent this complication from occurring.
All drugs can have detrimental side effects. You should discuss any concerns in this respect regarding the drugs prescribed for you with your Surgeon or Practitioner.
Platelet Rich Plasma
It has been found that the injection of platelet rich plasma can reduce pain and stimulate healing within joints and within injured soft tissues, particularly in cases of chronic ‘tendonitis’.
Platelets (thrombocytes) are small cellular fragments which circulate through the body with the blood. Their main function is to adhere to injured blood vessels and capillaries, which brings about their ‘activation’. This, in turn leads to the release of various enzymes and a number of complex a chemicals which initiate the localised clotting of the blood within injured areas to stop bleeding from the region.
In addition to clotting factors the platelets carry a number of ‘growth factors’ which aid the healing of the injured tissues, including bone, tendons, fascia and skin; as well as stimulating the in-growth of blood vessels to nourish the damaged tissue.
The platelet rich plasma is obtained by aspirating a small quantity of an individual’s blood which is then spun in a high-speed centrifuge to separate the various components of the blood. Once this has been done the platelets are held in the so-called ‘buffy zone’ which is aspirated off and injected into the painful and /or damaged soft tissues.
While there is anecdotal evidence of this technique being effective in some instances it has been criticized because some reports suggest that it is not effective in every case and, in addition, there are no reports of any randomised, comparative studies having been done.
Physical methods of orthopedic treatment
Maintenance or restoration of movement of an affected limb or joint is a fundamental aim of Orthopedic treatment and is of vital importance. In this respect exercise of the affected region is a basic Orthopedic treatment. The standard method of undertaking the necessary exercises is by way of Physiotherapy, while Osteopathy or Chiropractic therapy can also be very effective. There are, of course, those who already actively practice exercise activities such as yoga, tai chi or chi gong and would prefer to continue doing so. These alternative exercise methods can also be very effective in maintaining the suppleness and movement of the body but it must be recognised that they should supplement medical treatment, not replace it. Check with your doctor to ensure that you are physically fit enough before you begin undertaking any of these forms of exercise.
Splints, callipers, orthoses and traction – Canes and crutches relieve some of the weight through the legs and can help make walking easier when there is an injury or disease of the bone or a joint of the leg. Similarly callipers, which support one or more joints, are often used to help people walk when there is a weakness or deformity of one or both legs. Orthoses, i.e. artificial limbs, are generally used where the limb has been amputated for whatever reason and the person is able to stand to make use of it.
Diseases such as Rheumatoid arthritis damage the joints. Neurological damage, such as occurs with a stroke, can cause an imbalance of muscle action and lead to a contracture of one or more joints. In both such cases, where an arm is affected, it commonly results in a frustrating loss of function of the hand. This can often be helped by the use of an appropriate splint made by a qualified Orthotist (splint maker).
Simple fractures are often reduced (the malalignment of the bones corrected) and then held with an external cast until the fracture has healed. Similarly there are several techniques to apply a constant traction to a limb to reduce a fracture and hold it until it has healed. This form of treatment is not as common as it used to be as it generally requires a prolonged stay in hospital and it has become more expedient and efficient to operate on the limb.
Constant and progressive traction (usually with some form of external fixator) can be used to correct deformities of joints or to lengthen limbs.
Therapeutic massage has been used in many different countries, including China, India, the Middle East, Rome and Greece, for many centuries. While it is not clear as to exactly how it works it is mainly used to relieve musculo-skeletal pain, particularly myofascial ‘trigger spots’. In addition it has been recorded that physical massage can reduce anxiety and blood pressure. Presently massage therapy is practiced throughout the world by a wide variety of practitioners using a wide variety of techniques. In addition, self massage is a popular form of treatment for which a number of devices are available.
Ultrasound therapy – Ultrasound is often felt to be useful in several orthopedic situations. It can be used to image the underlying tissue and accurately guide needles and other instruments to specific sites or areas of damage within muscles, tendons and their sheaths, nerves, joints and blood vessels, so that drugs may be injected into them or localized procedures performed on them.
Low intensity therapeutic ultrasound is used to promote bone healing, both for recent fractures and for non-unions.
Ultrasound is particularly taken up by the soft tissues, such as the ligaments, tendons and fascia. It is said to soften the tissue in the target area, improve its blood supply and release scar tissue. As a result it is often used to supplement the treatment of painful conditions such as sprains, strains and fasciitis
Extra-corporeal Shockwave Therapy
Extra-corporeal shockwave therapy is similar to ultrasound except that it utilises short impulses of very high energy mechanical energy, although it can be used for treating the same range of conditions.
Electrotherapy – Although it is not clear as to exactly how it works, it has been found that, by reducing chronic pain, Electrotherapy can be helpful in a variety of musculo-skeletal conditions. Presently two systems are in use: Transcutaneous Electrical Nerve Stimulation (TENS) and Spinal Cord Stimulation. Both apply regular pulses of electricity which, depending upon the area of the body being stimulated, have specific shapes, duration and intensities.
The TENS is a non-invasive, portable system which is used mainly for localised myofascial pain. It consists of a battery operated control unit and a number of pads which are applied to the skin over the affected area. The shape, duration and intensity of the electrical pulses can be varied by way of the control unit. TENS can be a very effective treatment for chronic pain, particularly as a form of self treatment, although it must be accepted that most, but not every individual, will benefit from using it. In addition there are a number of caveats with its use and the following cautions should be observed and the unit NOT used:
- With the electrode pads over the eyes, as there is a risk of increasing intraocular pressure.
- With the pads across the head, as a seizure may be triggered.
- With the pads on the front of the neck as the vagal nerve pressure receptors in the carotid arteries may be stimulated, causing a fall in blood pressure.
- With the pads on either side of the chest, as this may cause an irregularity of the heart.
- The electrodes should not be used internally.
- The electrodes should not be applied directly over the spinal column.
- The electrodes should not be used over broken skin.
- The electrodes should not be used over a malignancy.
- The unit should not be used when a cardiac pacemaker is present.
The Spinal Cord Stimulator is a long term treatment of chronic pain mainly arising as a result of a chronic spinal or neurological condition. These conditions include the ‘failed back syndrome’, the ‘complex regional pain syndrome’ and ‘neuropathic pain’. Unlike TENS, this technique requires a surgical operation. The control unit is implanted under the skin and the electrodes are implanted into the spine. Being an implanted system it has a greater complication rate compared with TENS. These include lead migration, CSF leak, infection, and epidural hematoma. While between 50% and 70% of patients suffering from one of these conditions may benefit from spinal cord stimulation it is recommended that patients and their circumstances should be carefully reviewed before undertaking this procedure.
Pulsed electromagnetic fields (PEMF) is a non-invasive method which has been shown to enhance the healing of bony fractures where it is considered that delayed or established non-union is present. This applies especially to fractures of the tibia, which is notorious for developing this complication. The treatment is applied by the application of an electromagnetic coil to the leg in the region of the non-union. The devices are battery powered and the current passed through the coil in order to apply pulses of electromagnetism to the underlying bone.
Psychological methods of Orthopedic Treatment
Pain often brings about a sense of anxiety in the affected individual and, if it continues for any length of time, is often accompanied by a feeling of depression. In this regard psychological support is generally of great benefit. This type of support can come from your family, your general practitioner or surgery nurse, or it may take the form of patient support groups involving groups of individuals similarly affected, or from counsellors and psychologists who are trained in this form of care.
Complementary and Alternative Medicine (CAM)
Two Complementary Medicine treatments which can be of help with musculo-skeletal conditions are Acupuncture and Hypnotherapy.
There are two philosophical schools with respect to Acupuncture – Traditional Chinese Medicine (TCM) and Western Medical Acupuncture. The Traditional Chinese acupuncture is based on the concept that disease conditions arise as a result of an imbalance in the levels of the two types of ‘Chi’ i.e. the Yang (or masculine force) and the softer Yin (feminine) force. These forces are carried through the body by way of fourteen main channels (meridians) and a number of lesser channels. It is felt that where there is an excess or deficit of Chi in a channel it can be corrected by inserting fine needles at specific sites along it. In addition this can be supplemented by the application of heat at these sites (moxibustion) as well as specific herbal remedies.
The philosophy of Western Medical Acupuncture is slightly different. While it recognises the channels and insertion points it is circumspect about the existence of Chi. Rather it is proposed that the needles stimulate the nerves underlying the insertion points which then has a local effect on the tissue into which the needle is inserted, as well as both local and distal effects on the nervous system itself which bring about the beneficial effects.
Regardless of which system is used both modalities of treatment can be quite effective in the treatment of chronic pain, especially with back pain. The further advantages of these treatments are 1) that the complication rates are low and 2) the reduction in the level of pain may allow less analgesic medication to be used.
The idea that thought and the emotions affect the health of the body has long been known among Eastern civilizations. There has, however, been an increasing recognition of this in Western medicine over the last 30 years or more and the new science of Psychoneuroimmunology (PNI) is developing rapidly to investigate and utilise this.
It is now known and accepted that, through the connections in the brain, thoughts and emotions have a direct effect, for better or for worse, on the autonomic nervous system, the immune system, and the endocrine (hormonal) system. It is through direct nervous connections, and the resultant hormones and neuropeptides circulating in the blood these mental processes can, and often do, affect the whole body.
The main concern with Orthopedic conditions is generally that of pain, particularly chronic pain and a number of PNI techniques, hypnosis for example, are available which appear to be of assistance. Fibromyalgia and myofacial pain appears to be responsive to this form of treatment.
N.B. it must be stated that these CAM treatments should not be used as a substitute for medical treatment but, if used, should be as a supplement to the treatment and advice given by recognised medical practitioners. (In some, albeit few instances, one or more of these types of treatment may be administered by the practitioners themselves.)