The Orthopedic Center

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New Hampshire Orthopaedic Center

provides the most comprehensive orthopaedic care in southern New Hampshire. Our Board-certified and fellowship trained physicians and staff specialize in the surgical and non-surgical treatment of the spine, hand, shoulder & upper extremity, hip & knee, including reconstruction in total joint replacement, foot & ankle, trauma & fracture care, arthroscopic surgery, sports medicine and pediatric orthopedics.

In todays column we will not be talking about major trauma with deep lacerations, loss of consciousness, and fractures that obviously demand an immediate visit to the hospital ER. We will focus on conditions that
develop with little or no trauma and often in the home.

Unfortunately, the intensity of ones pain only loosely correlates with the gravity of the condition. For instance, consider the person with low grade shoulder pain that slowly becomes almost incapacitating. This is most likely acute bursitis which, though very painful, is not dangerous. Contrast this with a woman who feels fine one week after total knee replacement but wakes up to discover that her dressing is soaked with blood and joint fluid. This is an emergency because it could lead to a joint infection.

1. Shortness of breath, chest pain, and cough occurring one to three weeks after total knee replacement, total hip replacement, or hip fracture surgery. This could mean a blood clot to the lungs (pulmonary embolus).
2. Onset of calf pain and swelling a few days or weeks after injury or surgery on the lower extremity. This could be due to a blood c lot in the deep veins of the leg which might become an embolus to the lung.
3. A wound in a post operative patient that spontaneously starts to drain.

5. Increasing pain, swelling, and numb fingers or toes in a patient with a solid cast. This could be cast compression syndrome.
6. Acute severe back pain often accompanied by weakness in the legs and inability to empty ones bladder after lumbar spine surgery or epidural spinal injection. This could be due to bleeding around the spinal cord.
7. A child with a fracture, especially of the elbow, who has been treated for the fracture but remains uncomfortable and fussy despite medication. This could mean dangerous swelling at the fracture sight.
8. Any child who is crying, fussy, feverish and refuses to walk, without a definite injury. This could indicate a hip joint infection.
9. Any post operative patient who accidently falls or twists the operative limb and then experiences a marked increase in pain. This could mean a change in the fixation of the fracture, a new fracture, or, in the case of a total hip replacement, dislocation of the hip joint.
10. Any person with osteoporosis (usually a post menopausal woman) who has groin or thigh pain even after minor injury, followed by inability to walk. This could mean an insufficiency (osteoporotic) fracture of the hip.

This top ten list is not complete, but it does highlight common orthopedic emergencies. There are many other serious and painful orthopedic conditions not included on this list that should be seen by the orthopedist as soon as possible. If you are unsure, call your orthopedist.
Why Obesity Matters in Orthopedics or Extra Weight Means Extra Risk - By William P. Rix, MD
Posted: Tue Jul 27 2010 at 01:29:00pm
Its common knowledge that obesity is a medical risk for heart disease, hypertension, and diabetes. Did you know it directly impacts your orthopedic health as well?

One third of Americans are obese, with obesity defined as a body mass index (BMI) greater than 30 (see nhlbisupport.com to calculate yours). Carrying this extra weight contributes significantly to developing osteoarthritis in the weight-bearing joints. Compared to normal weight patients, orthopedic surgery on obese patients is more difficult, and results in more blood loss and longer operative times. In addition, post op complications such as wound infections, blood clots, and medical problems are significantly higher.

In major orthopedic trauma, obese patients sustain more complex fractures and have a higher mortality rate than their normal weight counterparts. Post-op complications in this group include an increased rate of hardware failure, fracture displacement, and nonunion.

As paradoxical as it sounds, many overweight people are actually under nourished, consuming empty calories devoid of necessary vitamins and minerals. This condition can lead to osteoporosis and poor wound healing.

The alarming nationwide increase in obesity in children is particularly worrisome. These children are at risk for slipped hip growth plates, bowing of the knees, and kneecap and foot problems. Many of these children have inadequate intake of vitamin D and calcium, so necessary for proper growth and optimal skeletal strength. This is something you cant make up after maturity is reached (see bestbonesforever.gov/parents).

What is the cause of this obesity epidemic? There are as many theories out there as there are fad diets. However, the short answer is that we overeat because we can, i.e., food is cheap and available. Unfortunately, much of this food is processed and fast food, which is loaded with sugar, fat, and salt. These are trigger foods that incite cravings which bypass the Im full signal. The biggest villain is sugary beverages which we consume on average of 50 gallons per person per year!

The solution to our escalating weight problem is complex, but as individuals we can take charge of our own lives and make healthful life style changes. Focus on one unhealthy habit, master that, and then start on a second. For instance, stop drinking soda pop, eliminate evening TV snacking, and dont skip breakfast our most important meal. Start exercising. This can be as little as 30 minutes per day, 3-5 times a week of uninterrupted walking, biking, swimming, gardening, or even housework. Avoid the latest fad crash diet in favor of moderation.

Posted: Thu Jul 15 2010 at 02:02:27pm
Youre at the doctors office and youve just been told you have arthritis. You nod your head knowingly, maybe repeating the term to yourself. But do you actually know what the word means? How about bursitis, or tendinitis? Whats the difference?
Lets look at these terms in some detail.

First of all, none of these terms is a diagnosis. They only tell part of the story. The suffix, itis, implies inflammation, whereas the base of the word refers to anatomy. For instance arth refers to a joint, burs to a bursa, and tendin to a tendon.

Arthritis, therefore, means joint inflammation. It doesnt tell you whether the arthritis is septic (due to infection), crystal (as in gout), inflammatory (as in rheumatoid), traumatic, or the usual wear and tear osteoarthritis. It doesnt tell you where it is, what part of the joint is involved, or what the possible cause is. For example, patellofemoral osteoarthritis due to malalignment of the extensor mechanism of the knee is a complete diagnosis. It tells you that the knee cap, as it articulates with the femur bone, is arthritic because the quadriceps-kneecap-patella tendon arrangement is not in true alignment and results in abnormal wear under the knee cap.

The same can be said for bursitis. A bursa is the thin closed sac that usually overlies a bony prominence onto which a tendon attaches. Bursae are found in areas of the body subject to friction. When the bursa becomes inflamed it swells, secretes fluid, and can become quite painful. The term bursitis means that the bursa is inflamed, but it doesnt tell you the cause of the inflammation. To make a definitive diagnosis you need a cause and a location. For example, subacromial bursitis is inflammation of the bursa overlying the insertion of the supraspinatus tendon in the shoulder. The supraspinatus tendon becomes inflamed, it swells, and the bursa is caught between the enlarged tendon and the overlying bony acromion. Being continually pinched, the bursa becomes swollen, secretes fluid and thickens, adding to more impingement. This can result in a very painful bursitis.

Tendinitis is a somewhat controversial descriptive term but is commonly used in orthopedics. It implies inflammation where a tendon inserts onto bone. The tendon's insertion becomes frayed and then inflamed as the body tries to repair it. Tendinitis in itself is not a diagnosis, but it does imply that at least part of the condition is due to excess stress at the bone-tendon junction. A classic example is Tennis Elbow (lateral epicondylitis) or Jumpers knee (patella tendinitis) seen in athletes.

Let`s carry this further, remembering that itis implies inflammation: synovitis is inflammation of the lining of a joint; capsulitis is inflammation of the tough fibrous capsule that encloses a joint; fasciitis is inflammation of the fibrous tissue overlying muscle, and neuritis is inflammation of nerve tissue.

Posted: Wed Apr 14 2010 at 04:01:46pm
Doctors are not much different from detectives. A crime has been committed (the health problem) and the perpetrator (diagnosis) is sought.

When you go to the orthopedist you have a chief complaint: pain, weakness, numbness, instability etc, and you have a clinical history: a timeline and description of your problem.

First, the doctor will determine the clinical history of the problem by asking a series of specific questions. After that, he or she will perform the physical examination. The data obtained from these exercises are the clues he or she uses to arrive at a conclusion. If at that point a diagnosis is not obvious, the orthopedist enlists tests that will provide additional clues: imaging, including x-rays, ultrasound, CT, MRI (looking for fractures, rotator cuff tears, ruptured discs, etc), blood tests (looking for rheumatoid arthritis, lyme disease, etc), nerve conduction studies (looking for neuropathies like carpal tunnel syndrome). In addition, your swollen joint may be tapped and the fluid examined for gout, infection, or bleeding.

If the perpetrator still has not been found, diagnostic trials maybe utilized and your clinical response carefully noted. These trials include physical therapy, splinting, and diagnostic injections. Occasionally, when the diagnosis remains elusive, the orthopedist will recommend a second opinion.

Fortunately, many cases are straight forward. For example, the patient slips on the ice (clinical history), the wrist is deformed (physical exam), an x-ray (imaging) is ordered and the suspected wrist fracture (diagnosis) is confirmed. However, contrast this with the elderly diabetic who presents with gradual onset of hip or back pain. In this case, the diagnosis is not clear cut and will require more complex investigation.

What can you do to help? Give a clear and concise history. Tell the doctor when the pain or disability started and what, if anything, precipitated it? What activities or maneuvers aggravate and relieve it? Characterize the pain, avoiding comments such as, I can really take pain, doc, but this one is a killer, in favor of the more helpful, This pain is so severe it wakes me up at night and prevents me from returning to sleep.

Your medical history is important: do you smoke, drink alcohol excessively, have diabetes, cancer, or rheumatoid arthritis? Have you had prior surgery, especially orthopedic procedures? Do you take any medications, particularly prednisone, blood thinners, or anticancer drugs?

You, the patient, hold the key to the diagnosis. The orthopedist cannot do this without your help. Be as objective as you can when detailing your history. Consider keeping a journal. The mind is notorious for suppressing details surrounding painful events.

Remember, you are part of the investigating team. With your help your doctor can solve the mystery, find the perpetrator and initiate treatment, all in a timely manner.
Imaging in Orthopaedics, or, A Pictures Worth a Thousand Words - By Dr. William Rix
Posted: Thu Feb 18 2010 at 12:57:06pm
Orthopedic Surgery specializes in abnormalities of the musculoskeletal system. This system includes bones and joints, ligament, muscles, tendons, and the associated nerves.

Orthopedists utilize imaging to help diagnose abnormalities of this system. As surgeons, we are always looking for mechanical causes for patients symptoms. For example, a ruptured lumbar disc pressing on a nerve root is a mechanical cause of leg pain; but inflammation of that same nerve root caused, for instance, by diabetes or Multiple Sclerosis, is not. Imaging is very good at revealing these mechanical causes for patients symptoms.

Plain x-rays are the gold standard of orthopedic imaging. They are excellent at showing bone detail. Quick, available, and cost effective, x-rays do involve ionizing radiation, but the dose per exposure is low. If the orthopedist decides that imaging is indicated for a patient, then the first step should be plain x-rays Two views are the minimum, and they are taken at right angles to each other. Weight-bearing views are used to evaluate arthritis. X-rays are excellent at detecting fractures, particularly in the long bones, but because the image is only two dimensional, it is sometimes difficult to detect subtle fractures in areas where there the bones overlap. Common uses of plain x-rays include emergency trauma evaluation and arthritis assessment, particularly in the large joints.

Computed Axial Tomography
CT scans are excellent at depicting bony detail, and they offer the advantage of doing so in a 3-D manner. Therefore, they are used for showing subtle pathology, particularly fractures in areas where the accuracy of plain x-rays can be limited, i.e. cervical spine, carpal bones of the wrist, tarsal bones of the mid-foot, and the pelvis. The computer-generated images give us frontal, cross sectional, and lateral cuts that show the bony abnormality in exquisite detail.
The downside of CT is that it is expensive and involves a significant amount of ionizing radiation. The radiation of one CT scan of the pelvis equals that of twenty chest x-rays. For this reason we order that test only if it is clearly superior to other forms of imaging. Common uses for CT in orthopedics include evaluation of major skeletal trauma in the emergency room and pre-operative planning in complex reconstructive surgeries about the hip & pelvis.

Magnetic Resonance Imaging (MRI)
MRI uses a large magnet plus a computer to generate images of the body. It is excellent at showing soft tissues (tendons, ligaments, cartilage, muscles) and body fluids (blood, pus, spinal or joint fluid). MRI is commonly used by the orthopedist because of its excellent imaging capacity and because it does not use ionizing radiation. It is great at illustrating torn menisci (cartilages), cruciate ligaments in the knee, and torn rotator cuffs in the shoulder. Since it reveals fluid so well, it can identify subtle microfractures which cause bleeding into the bone. These fractures might not be seen on plain x-rays or even CT. The major drawback of MRI is that it is expensive. In addition, one has to lie motionless for up to an hour, and that might be a problem for patients with claustrophobia. Because of the powerful magnet involved, MRI is contraindicated in patients who have certain metallic implants (pacemaker, vascular clips, ocular implants, etc).

Bone scanning involves injecting a radioisotope intravenously. The isotope concentrates in areas of the skeleton with high bone activity (fractures, tumor, infection). These areas of increased activity are seen as hot spots on the images generated. Bone scanning is very effective in identifying cancer that has spread to the skeleton. It is commonly employed by the orthopedist when a patient has vague bone pain, an equivocal x-ray, and/or a history of cancer. The disadvantages of this examination are that it uses ionizing radiation and that it is non-specific. In addition, lately there have been periodic shortages of the radioisotope. Still, it is a valuable scanning tool for identifying bone pathology.

Ultrasound uses sound waves to visualize soft tissues and fluids in the body. It is cheap, portable, quick, and involves no radiation. There are many potential orthopedic applications such as identifying torn rotator cuffs, looking for congenital hip abnormalities in the newborn, and diagnosing fractures with non-unions. A major disadvantage is that the results are very operator-dependent. For the results to be reliable, the operator must be very skilled and experienced with the techniques required for diagnosing each condition the orthopedist is investigating. For this reason, community orthopedists tend to use US primarily for detecting blood clots in the legs, a condition which is all too common following major orthopedic surgery.

Imaging is essential to the practice of orthopedics. However, imaging, especially MRI, does not make the diagnosis. Just as having a negative MRI does not mean that there is no orthopedic problem, having a positive MRI does not mean that the findings on the MRI are the cause of the patients symptoms. It is a combination of a good history and physical exam, coupled with appropriate imaging that allows the orthopedist to arrive at a diagnosis and formulate a plan for your recovery.
In Praise of Bones - By William P. Rix MD
Posted: Tue Jan 26 2010 at 10:34:51am
Did you know that bone is the only tissue in the body that heals with itself? If you cut your skin, it heals with scar tissue. If you lacerate your liver, brain, kidney, lung, it heals with scar tissue. If you fracture a bone, it heals with bone. It makes sense, doesn`t it? If the skeleton healed a broken bone with scar, an inferior tissue compared with the original, then it would be at risk for re-fracture at that site, even as we went about our normal activities. Early man would never have survived, for obvious reasons.

This illustrates one of bone`s important functions: Support. Bones support our frame whether we`re sitting, walking, lifting, or running the hundred yard dash. The bones are our scaffolding to which our muscles attach, propelling us along, flexing and extending at our joints. Muscles plus bones constitute our Musculoskeletal System. Orthopedic Surgeons specialize in the care and treatment of problems of this system.

Another bone function is Protection. The skull protects our brain, our rib cage protects our heart and lungs and our bony spine protects our fragile spinal cord.

A third function, one you might not realize, is Storage. Our skeleton is a veritable bank of calcium. Calcium is a critical regulator of many functions in our body. Some of the more important ones are muscle contraction, blood clotting, and intra cellular health. Our blood calcium levels are tightly regulated. When the body needs to increase its blood level of this mineral, it can`t wait until you have a glass of milk, or a cup of yogurt. When it needs calcium, it needs it now. One of the key ways it does this is to signal the bones to release calcium through a complicated mechanism involving PTH (parathyroid hormone). But, just like a bank that expects you to pay back the money you borrow, the bones expect you to replenish what you`ve borrowed by taking in an adequate amount of calcium in your diet. If the calcium is not replaced, the skeleton runs a deficit, and if this continues, you have a diminished Bone Mineral Density (BMD), which eventually leads to Osteoporosis. Osteoporosis is worrisome, and we will talk about this condition at some length in a future column.

The last major function of bone is Synthesis. Bone marrow is a semi liquid substance that resides in the center of our bigger bones, especially the flat bones like the pelvis and sternum. The bone marrow manufactures a variety of cells: red blood cells, which carry oxygen, white blood cells, which are important for immunity, and platelets, essential for blood clotting. In addition, bone marrow is a storehouse of pleuripotential mesenchymal stem cells. These stem cells, under the appropriate stimulus, have the capacity to turn into bone, cartilage, or muscle forming cells.

As essential as marrow is to life, there are several diseases, such as myeloma and leukemia, which target bone marrow. In such cases, bone marrow transplantation, along with radiation and/or chemotherapy, can be life saving.

Your skeleton is an amazing organ, and a few of its major functions are outlined above. In future columns we`ll talk about proper care of and common problems that affect this remarkable structure.
Wireless Internet Access
Posted: Mon Apr 27 2009 at 11:13:11am
For your convenience, we now offer wireless access while you are in our office. If youd like to take advantage of this access, please see one of our staff members for a security passcode.
ACL Injuries - By Gregory W. Soghikian, M.D.
Posted: Thu Feb 05 2009 at 02:34:50pm
ACL (anterior cruciate ligament) injury is the most common knee ligament problem that comes to surgery. Made famous by professional football players like Jerry Rice and skiers including Picabo Street, they are even more common now with the increasing popularity of sports, especially indoor and outdoor soccer.

The ACL is one of the knees central ligaments and helps to keep the top half of the knee from shifting out off the bottom half. If you are moving straight forward it doesnt get used much, but as you turn or shift direction quickly it comes in to play to keep the knee stable. While some ACL injured knees do not act very unstable for day-to-day activities, most wont put up with sports that require side-to-side motion and many may progress to cartilage injuries and arthritis over time.

While in the past ACL injuries and reconstruction were seen as career ending and life changing events, they are now viewed as just one more hurdle to cross by high level athletes. (Picabo Street has had 3). For the non-elite athlete ACL reconstruction was frequently reserved only for the very young or very active patient, and many were encouraged to just live with it. Advances in surgical techniques have significantly expanded the number of patients eligible for reconstruction.

ACL reconstruction surgery has evolved from something to be avoided unless absolutely necessary to a fine-tuned procedure with many technical options, relatively low risks and a high percentage of good and excellent outcomes. From a surgery that required a 5-7 day hospital stay and 6 weeks in a long leg cast, it has evolved to an outpatient procedure with early motion, rapid weight bearing and accelerated therapy with time away from work as short as a week. The range of patients who have reconstructions goes from teenagers to baby-boomers, from elite athletes to weekend warriors and occasionally couch potatoes. One of the largest increases in reconstruction procedures has been in middle-aged patients with ACL injuries that may have occurred 10 or more years ago. Dont misunderstand the surgical complexity of a reconstruction or underestimate the amount of time and effort patients go through to fully and successfully rehabilitate an ACL, but also dont be turned off by outdated information or age limits. If youve had a recent or an old ACL injury it should be carefully evaluated.

The details, choices and risks of both operative and non-operative treatment should be discussed with an orthopaedic surgeon who routinely does reconstructions, then the decision is yours.

Dr. Gregory Soghikian is an Orthopaedic Surgeon with New Hampshire Orthopaedic Surgery who specializes in Sports Medicine. A Magna Cum Laude graduate of Harvard University, he received his general surgical training at Massachusetts General Hospital and completed his Orthopaedic residency at George Washington University. He trained for an additional fellowship year in California concentrating on knee and shoulder reconstruction. Dr. Soghikian is a physician consultant to the World Professional Ski Tour and the New Hampshire Inter-Scholastic Athletic Association Sports Medicine Council. He was named by New Hampshire Magazine as one of the two best Sports Medicine surgeons in New Hampshire.