Orthopedics

Back Pain

A 30-year-old male presents with a one-year history of worsening lower back pain and alternating buttock pain. He mentions his symptoms are typically worse first thing in the morning, but seem to remit later in the day with NSAIDs and exercise. Physical examination reveals swelling of the proximal interphalangeal joints of several digits, restricted lumbar movement, and tenderness of the sacroiliac joint. An X-ray demonstrates the findings seen here. Which of the following extra-articular clinical manifestations is most commonly associated with this patient’s condition?

A) Blurred vision
B) Right lower quadrant pain
C) Plaques with silver scale
D) Shortness of breath

Click here for answers to this clinical conundrum

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Surgery for Torn Meniscus in the Knee is Often Unnecessary, Ineffective, Misdirected

  • Surgical meniscus repair was not superior to sham surgery in a randomized, controlled trial.
  • Non-surgical care of meniscus-injury related pain, such as exercise, was equally or more effective than surgical interventions.
  • Approximately 700,000 arthroscopic partial meniscectomies are performed annually in the U.S.
  • Annual direct medical costs are estimated at $4 billion.
  • Physicians and patients should consider all non-surgical options before undertaking surgical intervention for knee pain related to meniscus injury.

Studies Link Backpacks, Back Pain in Kids, Adults


  • Studies link heavy backpacks with low back pain in children.
  • Chronic low back pain in children is strongly linked to chronic low back pain in adulthood.
  • Low back pain is one of the most frequent causes of missed work days and long-term disability.
  • Backpack weight should not exceed 15% to 20% of child’s body weight.
  • Societies and associations have published backpack guidelines to reduce incidence of low back pain.
  • This cost-free healthcare could prevent extensive future medical interventions.

Spinal Fusion Surgery is Ineffective, Costly

  • Spinal fusion surgery is no more effective for pain resulting from degenerative disk disease than are exercise, education, and physical therapy.
  • Rates of a variety of spinal surgeries have soared in recent years in the U.S.
  • Published studies have repeatedly shown that spine surgery is often ineffective and dangerous.

Pre-Op Erythropoietin Reduces Transfusion Requirements After TKA, THA

  • The major finding of this review was that use of EPO reduced the need for allogeneic transfusion by approximately 60%.
  • Preoperative administration of erythropoietin (EPO) reduces the requirement for allogeneic blood transfusion following total knee arthroplasty.
  • Preoperative EPO was also found to increase postoperative hemoglobin levels.

Gabapentin Reduces Opioid Requirements Following Knee Surgery

  • Use of gabapentin was linked to decreased opioid consumption following total knee arthroplasty (TKA).
  • The use of gabapentin was also associated with a decreased incidence of pruritus in 6 randomized controlled (RCTs).
  • The meta-analysis included 859 participants.
  • No significant differences in Visual Analogue Scale (VAS) scores were detected between the gabapentin and placebo groups.

Tranexamic Acid Reduces Costs, Shortens Hospital Stay After Total Knee Replacement

  • Intra-articular tranexamic acid (TXA) reduces costs, transfusion rates, and length of hospital stay in patients undergoing total knee arthroplasty (TKA).
  • Blood transfusion rates were significantly lower when TXA was used.
  • Reduced transfusion rates and shorter hospital stays resulted in significantly lower costs.
  • Amount of blood transfused was significantly lower in cases where TXA was used.
  • TXA was infused directly into the knee joint via an epidural catheter following wound closure.
  • Overall cost saving was AU$631.36 (US$479.88) per patient.

Women at Increased Risk of ACL Tear; Allograft Makes Superior Repair

  • Anterior cruciate ligament (ACL) injury affects as many as 250,000 individuals in the U.S. annually, resulting in an annual health care cost exceeding $2 billion.
  • Women suffer ACL tears at 3x the rate of men.
  • Multiple reviews have found minor differences between single-bundle versus double-bundle surgical reconstruction techniques.
  • Analysis included 240 full-text articles.

Runners Experience Injuries at High Rates Overall, But Some are at Much Greater Risk. Why?

  • Runners who strike with greater force, increased vertical impact peaks, and increased vertical load rates have a higher risk for injuries requiring medical attention.
  • Higher impact forces at landing increased the risk of bony and soft tissue injuries.
  • Runners who have never been injured had the lowest impact loading of all studied groups.
  • Vertical average loading rate was the strongest predictor of injury risk.

Non-Invasive, Non-Pharmacologic Interventions Effective for Neck Pain

  • Episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises.
  • Patients with chronic tension-type headaches may also benefit from a variety of exercises, relaxation training, stress coping therapy, or multimodal interventions
  • Multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction was found effective for tension headaches.
  • For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine were found to be beneficial.
  • Review systematically analyzed 15 randomized controlled trials.

Minimally Invasive Spinal Fusion More Cost Effective in Every Way

  • Minimally invasive spinal (MIS) fusion results in lower direct and indirect costs.
  • MIS postoperative pain can be effective controlled with nonopioid epidural analgesia.
  • MIS results in fewer complications and greater patient satisfaction.
  • MIS is associated with reduced blood loss, decreased length of stay, decreased complication rates.

Meta-analysis Finds Exercise and Education Best for Back Pain

  • Meta-analysis includes 23 randomized controlled trials and more than 30,000 patients.
  • Surgery provides no clear benefit for most patients with back pain
  • Anti-inflammatory drugs plus exercise and education are most effective.
  • Rest found to exacerbate back pain.
  • Opioid analgesics should be avoided in the vast majority of cases.
  • Education alone, back belts, and shoe insoles offer no benefit.

Chondroitin Offers Moderate Benefit in Osteoarthritis, According to Meta-Analysis

When a patient asks whether it makes sense to use chondroitin for osteoarthritis, the following are appropriate responses:

  1. It may moderately reduce the pain in your knee.
  2. Consider the cost.
  3. Try a variety of therapies before you settle on one.
  4. Over-the-counter analgesics can also be effective, as can physical therapy, weight loss, and exercise.

Lumbar Spinal, Pelvic Stenosis: Disorder Exceedingly Common, As Are Therapies


  • Surgery proved to be one of the most effective treatments for spinal stenosis, according to a Cochrane meta-analysis.
  • There is no greater likelihood that a patient would receive relieve from an epidural steroid injection as that he or she would from no injection at all.
  • Steroid injections of various types are widely used and rarely effective.
  • Rehabilitation is essential to positive outcomes.

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