MRI Safety - Surgeon Information

The results of the MR safety tests for the Smith & Nephew devices indicated the following for the implants:

Titanium Intramedullary Nail - titanium Al/4V
Cobalt Chrome Staple - ASTM F75 cobalt chrome
Compression Hip Screw Plate and Lag Screw - 316L stainless steel
Oxidized Zirconium Knee Femoral Component - Oxinium material

Based on this MR safety test information, it appears that these Smith & Nephew implants will not present additional hazards or risks to patients undergoing an MR procedure using an MR system operating with a static magnetic field of 1.5-Tesla or less. As such, these devices should be considered “MR safe” according to the specific conditions used for testing.

This testing was performed using a shielded, 1.5-tesla 64 MHz MR system made by GE.
Regarding image artifacts, the report states:

For these devices, the artifacts that appeared on the MR images were relatively minor in relation to the size and shape of the metallic components of these devices. Basically the artifacts were shown as localized signal voids (i.e. signal loss) and distortions of the images.

External Fixators: Smith & Nephew’s policy is not to recommend MRI for patients with Ilizarov, Taylor Spatial Frame, or other external frames due to the possibility of magnetic field response causing undesired movement of the frame. Many of the accessory components of external fixators are made using hardenable stainless steels that do exhibit varying levels of magnetic permeability and it is not possible to guarantee use with MRI is safe.

Safety and magnetic resonance imaging

... Static hardware, including most of that used for orthopaedic and spinal work (with the exception of halo fixation devices), does not contraindicate magnetic resonance imaging; the procedure should, however, be stopped if patients experience pain in the region of large implants.1 Ventricular shunts used to treat hydrocephalus and most haemostatic clips do not pose problems.

Prevention of Secondary Osteoporotic Fractures -- Why Are We Ignoring the Evidence?

All orthopaedic surgeons are aware of the tremendous impact that osteoporosis has on our patients, and the public health implications of this are staggering. It has been suggested that the cost of treating the upcoming epidemic of femoral neck fractures alone may overwhelm the healthcare system.

Orthopaedic surgeons are in a position to identify many of these patients when they first present with a "fragility" fracture. For all of these patients, medical intervention is indicated. Many orthopaedic organizations, including the American Academy of Orthopaedic Surgeons, have made the identification of osteoporosis and the appropriate referral of patients for treatment a major initiative.

In this study, the authors (from Derriford Hospital, Plymouth, United Kingdom) looked at the first 100 femoral neck fractures operated upon beginning January 1, 1998. All patient notes, drug charts, and discharge summaries were reviewed 3 years later. The authors noted whether these patients suffered any further fractures associated with osteoporosis, prior to or since their hip fracture, and determined what advice and treatment had been documented in the records (if any).

The authors found that for almost all of the patients, the diagnosis of osteoporosis was essentially ignored, despite the well-known fact that such patients often present with further fractures. Only 3% of the patients were discharged on treatment for osteoporosis after their hip fracture. Twenty-three percent of the patients suffered later fragility fractures, and no further treatment was started in these patients despite refracture. Thus, a number of patients suffered 2 fractures associated with osteoporosis and still were not provided advice, referral, or simple, inexpensive therapies.

The authors concluded that orthopaedic surgeons are failing to initiate simple medical measures that not only improve the quality of life of their patients, but also would lessen the demands upon them to provide fracture care. The situation is likely very similar at many North American hospitals, and each of us should do everything that we can to ensure that these patients do not fall through the cracks of our disjointed healthcare system.

Unlike Rofecoxib, Celecoxib Not Linked to Increased Risk of MI

"Unlike rofecoxib, celecoxib does not appear to increase risk of myocardial infarction (MI), according to the results of a case-control study posted online Dec. 7 and published in the Feb. 1, 2005, print issue of the Annals of Internal Medicine."

Optimizing treatment of Osteoporosis

Optimizing treatment of Osteoporosis

Wonderful Flash slide presentations!

Prolotherapy - in Chronic Low Back Ache

"Prolotherapy, also known as 'sclerotherapy,' is a controversial treatment that has been the subject of much skepticism by traditional medicine. It consists of a series of intraligamentous and intratendinous injections of irritant solutions administered near trigger points to treat chronic pain. Although it has a strong foothold in the alternative and osteopathic medical communities, its efficacy has not been supported in clinical trials. Proponents of the therapy suggest that laxity in the ligaments and tendons around the joints causes pain by inducing muscles to contract and irritate nerve endings. Repeated injections with irritant solutions is believed to produce new collagen deposition, which is intended to support the injured or loosened ligaments, creating a more stable and strong muscle base, thus alleviating pain and disability. There are 3 classes of proliferant solutions: chemical irritants (eg, phenol, guaiacol, tannic acid, and pumice flour), osmotic agents (eg, hypertonic dextrose, zinc sulfate, and glycerin), and chemotactic agents (eg, sodium morrhuate, a fatty acid derivative of cod liver oil). Prolotherapy protocols usually include co-interventions to enhance the effectiveness of the injections."

Glucosamine in OA - an Internet based RCT

"The investigators' goal was to demonstrate the feasibility of performing a clinical trial purely over the Internet, rather than assess the efficacy of glucosamine alone. However, their findings were consistent with another recent study by Cibere and colleagues,[1] who evaluated patients with knee osteoarthritis who had experienced at least moderate subjective improvement with previous glucosamine use in whom the medication was discontinued. In their trial, no evidence of symptomatic benefit from continued use of glucosamine sulfate was demonstrated, and no differences were found in severity of disease flare or other secondary outcomes between placebo and glucosamine patients.[1] (This is in contrast to several industry-sponsored glucosamine trials that have demonstrated positive results.) Furthermore, physicians should be aware that supplements are costly and not covered by insurance; further studies are needed to resolve the question of efficacy."

Complex Regional Pain Syndrome

The National Institute of Neurological Disorders and Stroke (NINDS) defines complex regional pain syndrome (CRPS) as a chronic pain condition that is believed to be the result of dysfunction in the central or peripheral nervous system.[1] It describes the key symptom of CRPS as a continuous, intense pain out of proportion to the severity of the injury (if an injury has occurred), which worsens over time.

Long-Term NSAIDs May Not Be Useful for Osteoarthritis

"Nonsteroidal anti-inflammatory drugs (NSAIDs) offer only a small, short-term benefit that may not be clinically significant for people with knee osteoarthritis (OA), according to the results of a meta-analysis published in the Nov. 30 Online First issue of the BMJ. Due to the long-term harm and lack of demonstrated benefit, the investigators recommend against long-term use of NSAIDs for OA."

Vertebroplasty May Reduce Kyphosis in Selected Patients

Percutaneous vertebroplasty (PV) may reduce kyphosis in selected patients, according to the results of a study published in the December issue of Radiology. "Since its description, the objective of performing percutaneous vertebroplasty (PV) has been to treat pain in vertebral metastatic or compression fractures that are unresponsive to conventional treatments," write Robert Y. Carlier, MD, from the Hôpital Raymond Poincaré, in Garches, France, and colleagues. "To our knowledge, no randomized controlled study has shown a benefit beyond that of placebo in osteoporotic vertebral collapse fractures."

Facet Syndrome

Facet syndrome occurs as a result of synovitis or disruption. It is expressed as local pain in the region of the transverse processes, and referred pain radiating to corresponding segments if the nerve root emerging between the transverse processes is also damaged. Affected patients complain of low back pain, which is often prolonged. The pain may radiate to the groin, trochanter region, sacroiliac region, front or anterolateral aspect of the thigh as far as the knee, and even through the lower leg as far as the foot. Dull cervical pain radiating to the shoulder and arm may also be reported by some patients. The pain of facet syndrome is position-dependent and is experienced – often as ‘darts' of pain – when the patient stands up or takes his or her first few steps in the morning. Unlike intervertebral disc prolapse, facet syndrome is not associated with segmental pain, paraesthesia or neurological deficits (including sciatic malposture and the Lasègue phenomenon).

Facet Syndrome

Facet syndrome occurs as a result of synovitis or disruption. It is expressed as local pain in the region of the transverse processes, and referred pain radiating to corresponding segments if the nerve root emerging between the transverse processes is also damaged. Affected patients complain of low back pain, which is often prolonged. The pain may radiate to the groin, trochanter region, sacroiliac region, front or anterolateral aspect of the thigh as far as the knee, and even through the lower leg as far as the foot. Dull cervical pain radiating to the shoulder and arm may also be reported by some patients. The pain of facet syndrome is position-dependent and is experienced – often as ‘darts' of pain – when the patient stands up or takes his or her first few steps in the morning. Unlike intervertebral disc prolapse, facet syndrome is not associated with segmental pain, paraesthesia or neurological deficits (including sciatic malposture and the Lasègue phenomenon).

Unlike Rofecoxib, Celecoxib Not Linked to Increased Risk of MI

"Unlike rofecoxib, celecoxib does not appear to increase risk of myocardial infarction (MI), according to the results of a case-control study posted online Dec. 7 and published in the Feb. 1, 2005, print issue of the Annals of Internal Medicine."

Course of Nonsurgical Management of Burst Fractures

"The present study revealed that an intact posterior ligamentous complex might not prevent loss of correction gained by nonsurgical management of burst fractures. Significant loss occurs in the first 3 months despite external stabilization. However, the magnitude of residual deformity usually remains close to the initial deformity. Although changes in the shape of adjacent discs occur due to trauma and/or natural course, significant loss in signal intensity of nucleus pulposus is unlikely. Patient outcome seems to be highly satisfactory despite residual deformity."

Traction Radiography Often Helpful in Evaluating Scoliosis

"Traction radiography performed under general anesthesia (TUA) is better at evaluating curve flexibility for scoliosis repair than the current standard, supine bending, according to the results of a prospective study published in the Nov. 1 issue of Spine."