Articles Posted in Orthopedic Injuries

A new MRI muscle imaging technique has been developed that allows detailed large scale 3-D images of the body’s complex muscle structures. It also provides a means of detecting muscle damage precisely. Expanding further on the utility of diffusion tensor imaging, the technique captures the movement of water molecules within muscle fibers to detect changes in fiber directions. Moreover, the technique allows reliable 3-D imaging to be captured so that the images can be viewed from different directions. It is expected that the imaging will be useful in the treatment of chronic conditions, such as post-polio syndrome and diseases causing muscle atrophy, sports injury rehabilitation, and trauma.

Source: Eindhoven University of Technology, News Release, 10/30/2012.

Mr. O’Donnell recently successfully concluded a jury trial against a defendant who caused a head-on collision on the Seward Highway. The defendant was driving her vehicle while intoxicated and had allowed her vehicle to cross the centerline.

Stovall%201.JPG

The plaintiff, a young woman, suffered extensive hip, leg and foot injuries. The jury awarded an amount in excess of the statutory limit for non-economic damages. Non-economic damages include damages for pain and suffering, loss of enjoyment of life, disfigurement, physical impairment, and inconvenience. The total judgment, including stipulated medical expenses, totaled $4.2 million.

The Alaska Personal Injury Law Group, consisting of Neil O’Donnell, Mike Moody and Rick Vollertsen, has successfully resolved, either by way of jury verdict or settlement, numerous serious automobile claims over the past three decades. Through this track record they have developed extensive experience working with the medical, engineering and economic experts needed to successfully present such claims for their full value. Such experts include accident reconstruction engineers, biomechanic engineers, rehabilitation experts and economists.

Two studies in the New England Journal of Medicine have concluded that arthroscopic surgery doesn’t improve patient outcome for those suffering from arthritis of the knee. In the first study, 200 patients with moderate to severe knee arthritis and no meniscal tears were placed randomly into surgical and nonsurgical groups. At two years, the complaints of pain, stiffness, and physical function did not differ between the two groups.

These findings comport with those of a 2002 study reported in the NEJM. There, 180 patients were studied using a placebo procedure, an arthroscopic lavage, and arthroscopic lavage with debridement. Again, at two years, there were no significant differences between the groups on scores for pain and physical functioning.

The conclusion is that arthroscopic surgery is ineffective for most patients with knee osteoarthritis.

Under the dubiously named Dietary Supplement Health and Education Act (DSHEA), diet supplements and herbal preparations are not approved by the Food and Drug Administration for medical use in humans. Thus, safety and formulation are solely the responsibility of the manufacturer; evidence of safety and efficacy is not required as long as they are not advertised as a treatment for a medical condition. As we have seen in diet supplement litigation (Talbert v. E’ola Products, Inc.), diet supplement manufacturers often promise the moon in selling their products to the consumer, while having little other than anecdotes to show when it comes to providing data for the safety or effectiveness of their products. Even assuming that the products are not adulterated (because of shoddy manufacturing protocols), have not been spiked (pharmaceutical drugs intentionally put into the supplement), and actually contain the ingredient at the levels claimed (often the “active” ingredient is missing or varies wildly), it is the exception, not the rule, that the manufacturer will have evidence that the supplement is safe for human consumption and actually works. With pharmaceutical drugs, the manufacturer foots the bill for such research. In the world of diet supplements, however, it is often independent researchers or the government (read: the taxpayer) that is burdened with the duty and cost of proving the safety and efficacy of a particular diet supplement.

At the Alaska Personal Injury Law Group, we are frequently asked to help those with serious orthopedic injuries. And our clients commonly face the debilitating consequences of arthritic changes that come from these injuries. So a discussion about glucosamine is in order. Luckily, unlike ephedra and other more dangerous diet supplements, glucosamine has not had a string of serious adverse events (it is not without side effects, however, so you need to read carefully before using glucosamine). But does it work?

Glucosamine is a natural compound that is found in healthy cartilage. Glucosamine sulfate is a normal constituent of glycoaminoglycans in cartilage matrix and synovial fluid (this is the “hydraulic” fluid in your joints). It is believed that the sulfate moiety provides clinical benefit in the synovial fluid by strengthening cartilage and aiding glycosaminoglycan synthesis. The question is, if you take the supplements, will the body put the critical compounds into your blood stream and use them where the arthritis lies? There have been multiple clinical trials of glucosamine as a medical therapy for osteoarthritis, but the results have been conflicting. Early clinical trials sponsored by a European patentholder, as expected, demonstrated a benefit from glucosamine. However, these studies were of poor quality due to shortcomings in their methods, including small size, short duration, poor analysis of drop-outs, and unclear procedures for blinding. Subsequent independent studies did not detect any benefit of glucosamine. This situation led the National Institutes of Health (yes, you the taxpayer) to fund a large, multicenter clinical trial studying reported pain in osteoarthritis of the knee, comparing groups treated with chondroitin sulfate, glucosamine, and the combination, as well as both placebo and celecoxib (Celebrex). The results of this 6-month trial found that patients taking glucosamine HCl, chondroitin sulfate, or a combination of the two had no statistically significant improvement in their symptoms compared to patients taking a placebo.

When we represent clients at the Alaska Personal Injury Law Group, we do our homework. When serious injuries occur, we have to become experts ourselves in the particular medicine being used to treat our clients. We thus comb through and rely extensively on medical literature in virtually every case we handle. We use it in our work with the medical experts we engage to help our clients, and we also share it with our clients.

And whether you realize it or not, you rely on medical literature every time you see a doctor or take any medication. This is because the engine of medicine runs on the data from medical literature. That data is what the FDA uses to decide whether to allow a medication or medical device to be sold, and what your doctor relies on to decide if a treatment, medical device, or medication will help you. Extraordinary rules and guidelines are put in place to make sure that the scientific findings in a particular study are objective and scientifically verified.

So it is always shocking when we learn that a manufacturer has taken liberties with the research data to make it appear that their product works when it really doesn’t. (We saw this repeatedly in the litigation against diet supplement manufacturers: Talbert v. E’ola Products, Inc.) We know why this happens: millions and sometimes billions of dollars are made by manufacturers in these endeavors, and greed can be a powerful motivator. Every time we learn about one of these situations, it reaffirms the need to vigilantly enforce the principles that guide regulators and researchers who develop research data. Western medicine is so profoundly effective because it is “evidence-based medicine”. If we allow clinical researchers to get into bed with the manufacturers, how can we trust that the research data they create for the manufacturers is valid, objective and truly “evidence-based”?

Clients of the Alaska Personal Injury Group often have to decide whether to have knee surgery. When the underlying cause of pain and discomfort is arthritis in the knee, rather than a mechanical problem like a torn ligament, the arthroscopic surgery proposed by orthopedists is often not helpful. A surgeon will admit this if pressed, and now there is a study that addresses this very issue.

In an article just published in the Cochrane Database, researchers studied the outcomes of arthroscopic debridement surgery in patients with knee arthritis after reviewing the published literature regarding such surgeries. The researchers found that arthroscopic surgery does not improve pain or ability to function when compared to simple placebo and sham surgery. They also concluded that arthroscopic surgery led to little or no difference in pain levels or the ability to function in comparison to simple lavage (washing out) of the knee joint. Further, having arthroscopic surgery also comes with the additional risks of surgery, such as pain, infection, or embolism. The cautions that come with relying on this data is that the authors ultimately relied on only 3 out of the 18 studies they reviewed, and it is clear that some patients with particular injuries can be helped with arthroscopic surgery. The trick is for the patient to figure out if they are really in that small subset of patients who can be helped by the procedure.

With arthroscopic surgery of questionable value where no operable condition is causing their problems, clients are thus faced with relying on more conservative measures to ameliorate their pain and limitation from knee arthritis, such as physical therapy, viscosupplementation (injecting a cushioning fluid into the joint space), and medications to forestall more serious surgery like total knee replacement.

One of the unfortunate outcomes of serious orthopedic trauma faced by the clients of the Alaska Personal Injury Law Group is surgery for injured spinal discs. Whether it is soon after an accident like an automobile crash, or years later due to progression of their condition, clients often struggle with the decision about whether to have spinal surgery.

A harsh reality is that the “gold standard” in cervical disc surgery is removal of the herniated disc and fusion of the joint with bone and metal plates. The unfortunate results of this type of surgery often include recurrence of the original neck, back and arm pain, a limitation of neck movement, and increased stress on adjacent spinal levels that leads to arthritic changes in that joint, and sometimes yet another fusion. When a person’s own bone is taken for the fusion from the iliac crest of the hip, that operative site can also be a source of pain or disability.

In recent years, there have finally been some advances in spinal surgery for herniated discs with the development of disc implants intended to avoid fusion and preserve joint movement in the injured vertebral segment. There are several manufacturers now performing clinical studies of their new implants. In the journal Spine, a two year study of the Bryan cervical disc implants was just published. The researchers followed 115 patients, 56 of whom had the new implants. Their study showed that the patients receiving the implants had less arm and neck pain when evaluated at one and two years after surgery, and they retained greater neck movement than in the patients receiving a fusion. The researchers believe that retention of greater movement will ultimately lead to less biomechanical stress on adjacent joints, and therefore to less injury to surrounding joints.

A common problem an attorney has is how to be certain their client is receiving proper medical care. The attorney can collaborate with the client to be sure that the proper diagnostic steps are being taken. This not only helps further a client’s case, but it also helps the client return to function. It is often the case that a better diagnosis can be obtained depending on what type of films are taken. A current debate is whether the MRI or arthroscophy is preferable in diagnosing a knee injury. Both have shown good diagnostic performance in detecting lesions of the menisci and cruciate ligaments. Nonetheless, arthroscopy has remained the “gold standard”.

The British Medical Bulletin recently published an article examining this question. As might be expected, the answer was, “well, it depends”. The results of the study were that MRI was deemed “highly accurate ” in diagnosing meniscal and anterior cruciate ligament (ACL) tears. Because its use avoids the risk of surgery, it is “the most appropriate screening tool” before arthroscophy is performed. The results differed, however, depending on whether the medial and lateral meniscus and ACL were being examined.

British Medical Bulletin 2007 84(1):5-23.