Monthly Archives: September 2016

External Fixator to Volar Plate

by Alejandro Badia, MD

It was not too long ago that the standard of care for a distal radius fracture with displacement was the application of an external fixator. Like the brief internment in a penal colony, the patient was left to deal with this cumbersome device for several months. I highly doubt that many of the little old ladies who had this device applied appreciated its “minimally invasive” nature.

Over 10 years ago, I remember my partner and I applying the standard volar plate from the synthes set to ALL distal radius fractures, regardless of direction of  displacement. I think neither Mrs. Smith nor Mrs. Colles cared about their Frykman classification but likely appreciated the fact that a small palmar based plate on the wrist, as an outpatient under regional anesthesia, could allow them to get right back to their daily routine simply using a small splint or fiberglass cast as protection.

I remember just a few years later lecturing on this very topic in Ho Chi Minh City, or even Buenos Aires, and realizing that this had very quickly become the standard of care worldwide. It was gratifying to be part of a revolution that truly improved patient care of this ubiquitous fracture.

Alejandro Badia, MD

Badia Hand to Shoulder Center

Miami, FL, USA

Energy Transfer: Be Additive.

 by James D. Hundley, MD

            If you’ve never been a patient with a serious problem yourself, you may not have considered this.  Having a medical problem not only drags down your body, it drags down your mind, too.  I’m sure someone taught you about it in medical school, but when we get wrapped up in the technical side of our profession, and it’s absolutely necessary that we do so, this is a lesson that some seem to forget.

Do you know people who are “buzz killers”?  Within a few seconds of being in their presence, you feel your emotional energy being drained and you can’t get away from those people quickly enough.  In contrast, those who are bright and energetic make you feel good and ready to tackle anything.

This is true in the doctor-patient relationship, and it’s serious.  I’ve been around doctors who act so down in the dumps that it seems that they are the ones who need help more than their patients.  Maybe they are tired from working so hard or maybe they are internalizing their worry about the patient, but they sure aren’t helping their patients tackle their problems.  Whatever the case may be, they are sucking needed emotional energy from their patients rather than filling their patients’ tanks with the fuel they need to deal with their problem.

I’m not suggesting that you not show concern.  To the contrary, I’m suggesting that you not only show concern for and interest in your patients, I’m suggesting that you be truly concerned and show it by transferring some of your own positive energy to your patients.

You can’t be silly or trivial.  That’s not what I’m suggesting.  It might take a little practice to find your own best way of approaching this and it’s hard to describe, but it’s about being positive and upbeat to the extent possible in any given situation.

Players play better for certain coaches.  You frequently hear about it.  I’ve seen it with teams that I’ve worked with.  The same players who were losing miraculously start winning.  Surely the reasons for the sudden success are many.  Maybe it’s conditioning or technique.  They’re important.  Without positive energy, however, I don’t think it happens.

Likewise, when you rod someone’s femur or replace someone’s hip, the technical aspects are critical, but that’s not enough.  You have to take care of the other physical needs as well, and I’m sure you do, but that’s still not enough.  You must also help that patient find the energy to get up and go again.  Equally as important, no matter how tired you are or what else is going on with other patients or in your life, you must dig down and find positive energy to share with your patient.

Many will dismiss this as insignificant and/or unrealistic.  I have no scientific studies to support it.  On the other hand, I have had many years of interaction with patients and truly believe that patients do better when they want to please their doctors.  It’s like a player wanting to please his coach.  You can’t fall into the trap of thinking it’s about you personally, of course, but if it’s useful to the patient, it’s certainly not harmful.

Worried that all of your energy will be drained by your patients?  Don’t be.  In fact, the gratification of seeing your patients happily improving or resolutely dealing with serious problems is in itself a source of energy for you.  It’s like heat reflecting off an object and back to you.  Try it.  You either already know that it’s true or you’ll be pleasantly surprised.

Dr. Hundley is a retired orthopaedic surgeon living in Wilmington.  He is the founder and president of OrthopaedicLIST.com a resource website for orthopaedic and other surgeons and related professionals.

How to Tear Tape

by James D. Hundley, MD

You may think that this is silly, but it’s one of those “essential” techniques you don’t learn in the classroom.  Have you ever struggled to tear off a strip of adhesive tape to apply a dressing?  If you’re not in the medical profession, how about tearing duct tape?  Can you do it?

It seems like it takes three hands to hold and cut tape with scissors, and scissors are not always available or accessible.  Typically they are in the wrong pocket and you can’t easily reach them with your free hand.

I don’t know when it was in med school that a tiny little nurse embarrassed me by deftly tearing off a strip from a roll of wide adhesive tape.  I had made a mess of trying and she got a kick out of making fun of me.  Then she taught me how to do it.

It’s simple but not intuitive.  Most people will hold the tape in both hands and try to twist and tear it.  That feels like the natural way to do it, but it bunches up the tape at the top edge and makes the tear hard to start.

The “correct way” is to grasp the tape between the thumb and index fingers of both hands and then pull apart the top edge without twisting the tape.  Think of turning the palms from the palm-down into the palm-up position (i.e. supinating them) while pulling the top edge of the tape apart.  If you can’t pull hard enough without some leverage, you can roll your hands outward leveraging on the backs (dorsal aspects) of the otherwise unused long, ring, and small fingers.  Just don’t twist it.

You can do this.  It just takes a little practice.  Then you can enjoy embarrassing your co-workers and some novice medical student yourself.

Tearing apart telephone books is a different matter.  Maybe we’ll address that sometime in the future.

Dr. Hundley is a retired orthopaedic surgeon living in Wilmington.  He is the founder and president of OrthopaedicLIST.com a resource website for orthopaedic and other surgeons and related professionals.

Using a Soft Tissue Force Sensor in Total Knee Replacement Arthroplasty, Discussion and Case Report

by Scott Hadley, MD and Joseph Fetto, MD

 ABSTRACT

An 82-year old female patient with a fixed 20 degree valgus deformity of her right knee underwent total knee replacement with complete deformity correction with a non-constrained knee design. Preoperatively, the patient’s right knee range of motion was limited to 20 – 110 degrees of flexion with a 20 degree fixed valgus deformity. She was confined to minimal housebound ambulation with a walker. The pt underwent a total knee replacement under epidural anesthesia with intraoperative use of the eLIBRA™ Soft Tissue Force Sensor to assist in soft tissue balancing. No lateral soft tissue releases were needed. The valgus deformity was corrected intra-operatively and ROM achieved 10 – 120 of flexion. By 6 months post-surgery, the patient had achieved 10 – 130 degrees of right knee flexion, and complete correction of her valgus deformity.

INTRODUCTION

Total Knee Replacement (TKR) is a highly successful procedure which can reduce pain and improve range of motion and function by correcting angular deformities and restoring the integrity of articulating surfaces.1–3 TKR, however, is a misnomer as this operation does not actually “replace” the knee joint as is the case of Total Hip Replacement procedures. Rather it is more accurate to describe TKR
as a re-surfacing of the knee joint. Classically, TKR was accomplished with bony cuts which may be supplemented with soft tissue releases, prior to affixing the component parts, by either cement or non-cement techniques, to the bony surfaces. Over the past three decades, instrumentation has been developed to make the outcome of a TKR more reproducible and predictable.4 However, maximizing simultaneous restoration of range of motion (ROM) and stability has remained a significant challenge.

The knee is an inherently unstable articulation, with two large convex condylar surfaces resting on a relatively flat tibial plateau. Its stability, functionality and longevity are totally dependent upon soft tissues: ligaments, muscle-tendons and to a lesser degree the medial and lateral menisci.

In the knee there are four major ligaments (MCL, LCL,
ACL and PCL) that form the static stabilizers of the joint. Each ligament is composed of two parts, one part maximally tightens at the extreme of flexion and the other at the extreme of extention. Compromise of the structural integrity of any of these major ligaments creates significant knee instability, accelerated wear and dysfunction of the articulation. In addition to these four major ligaments, there are many minor ligaments distributed about the perimeter of the knee. As well, there are transversely directed ligaments attached to the medial and lateral aspects of the distal femur which serve to stabilize the patella within the femoral trochlear groove.

The patella is a sesamoid bone imbedded within the quadriceps mechanism. As such, its tracking is determined by the anatomic relationship between the dynamic quadricepsmuscle, the geometry of the trochlear groove and the by the patello-femoral ligaments. The pelvis is wider than the distance between the knees and as a result the normal femur and tibia are not aligned in a straight line, but rather at a 5 – 7 degree valgus angle. This orientation of the bony structures results in a laterally directed force being applied to the patella with active contraction of the quadriceps. This laterally directed force is resisted by a combination of the oblique fibers of the vastus medialis muscle (VMO) dynamically, and statically by the medial retinaculum and the medial patello-femoral ligament.

The muscle-tendon structures at the knee provide dynamic stability, over which an individual may exert some measure of control. Anteriorly, the quadriceps-patellar tendon mechanism, with its broad retinacular expansion, is responsible for active extension and resistance of flexion of the knee. Posteriorly, the medial and lateral hamstrings are well positioned to actively flex the knee, decelerate knee extension and provide some dynamic rotational stability. In addition across the postero-lateral aspect of the knee, there is an obliquely oriented, “upside-down”, popliteus muscle.
Its function is to assist in control of internal rotation of the femur on the tibia, thereby modulating rotational stresses transmitted to the weight-bearing knee through the ankle due to pronation of the subtalar joint.

With such complexity of soft tissue structures determining knee stability and function, it is obvious how important the restoration of “soft tissue balance” is to the successful outcome of a TKR procedure.2,5

There have been significant evolution and development in TKR instrumentation over the past three decades, beginning from very simplistic rectangular “cutting blocks”, which crudely served to determine the location and orientation of femoral and tibial bone resection cuts, to advances in computer assisted navigation, “customized” instrumentation and application of robotic technology designed to restore “normal anatomy”.4, 6–9 While these technological advances have the potential to more accurately guide the surgeon in the restoration of bony alignment, they do not and have not yet resolved the problem of how to accurately and reproducibly restore the soft tissue balance to the damaged knee.

Today “soft tissue balance” is assessed in a very subjective manner. After implantation of provisional components the surgeon visually inspects the ROM of the knee, the tracking of the patella and manually tests medial / lateral, posterior / anterior knee stability by applying stress in the appropriate directions with the knee in full extension, mid-range and full flexion. If not satisfied with the result achieved he / she may then choose to perform what are termed “soft tissue releases” or re-cut the bones, based on what is felt to be lacking in the reconstruction. Most commonly, dissatisfaction occurs due to poor patello-femoral tracking with knee flexion and/or limitation in ROM. Unfortunately, today’s standard of practice does not supply surgeons with any objective methodology or tool with which to measure the result achieved or improve the likelihood of achieving the outcome desired.

In an effort to address this deficiency, a new instrument has been developed which can objectively measure the relative pressures within the medial and lateral compartments before final bony cuts are performed. It is designed to equalize the compressive pressure within the compartments by the controlled application of a distracting force. In so doing this device will permit appropriate internal / external rotational orientation of the femoral component, relative to the longitudinal axis of the femur, and in so doing achieve “soft tissue balance” of the tissues, particularly those responsible for static control of patello-femoral tracking. This device (eLIBRA™ Soft Tissue Force Sensor manufactured by Synvasive, El Dorado Hills, CA) may reduce the necessity of certain soft tissue releases being performed, such as lateral patellar retinacular release.

This case study is presented to demonstrate the use of this device and the possible clinical application in an arthritic knee with a severe flexion-valgus deformity.

 CASE REPORT

N.H. is an 82 year old, slightly built white female with an atraumatic progressive painful deformity of her right knee. The patient had become limited to minimal housebound ambulation requiring a walker and/or wheelchair for independent mobility within her home. She had difficulty transferring from a sitting position and could no longer negotiate stairs without assistance. As a consequence of her growing dependence on her uppe extremities, the patient was developing bilateral carpal tunnel, ulnar nerve irritation and shoulder discomfort. Her pain was in proportion to her activities and was unresponsive to NSAID medication. She had a history of blunt trauma to the right tibia after a fall that was complicated by a brief period of cellulites, treated successfully with oral antibiotics. Otherwise, she had no history of co-morbidities related to her knee complaints.

On physical examination the patient was found to be an alert, oriented female sitting in a wheelchair in no apparent distress. However on attempting to stand and bear weight on the right lower extremity she had significant discomfort. She was able to remove her shoe and stocking from the left foot but required assistance with her right foot. The skin over the right lower extremity was intact and there was no effusion, soft tissue swelling or erythema about the right knee. The right knee was held in a flexed posture. The right knee ROM was relatively painless but limited to 20 –110 degrees of flexion with a 20 degree fixed valgus deformity. (Figures 1 & 2) There was significant crepitus within the patello-femoral and lateral compartments throughout the ROM. ROM of the left knee and both hips were painless and within normal limits. Her left foot had a mild equino-varus contracture limiting left ankle dorsiflexion to -5 degrees from neutral, due to disuse and posterior soft tissue contracture. There was tightness in the posterior calf musculature with the right foot and ankle limited to 0 degrees of dorsiflexion, 30 degrees of plantar flexion, and a fixed 10 degrees of pronation in the subtalar joint. Neurovascular supply to both feet was intact.

X-rays demonstrated a significant valgus deformity of the right knee, erosion of lateral femoral condylar bone and severe tri-compartmental osteo-arthosis. After exhausting all conservative options of treatment, the patient was indicated for right total knee replacement.

The patient underwent a TKR with epidural anesthesia, intra-operative foot pumps and minimal tourniquet utilization except during cementation of the TKR components. The eLIBRA™ Soft Tissue Force Sensor was used to determine optimal external rotation positioning of the femoral component before completion of femoral cuts. (Figure 2) Care was taken throughout the procedure to avoid placing excessive stress on the peroneal nerve. Intra-operatively the patient received a non-constrained TKR with a 9 mm polyethylene insert. The patella was re-surfaced with a 9mm thickness polyethylene component. ROM achieved intra-operatively was 10 – 120 of flexion with no valgus deformity. Post-operatively the patient’s treatment included: routine DVT prophylaxis with epidural PCA × 48 hours, 325mg. enteric coated aspirin, gentle progressive active and active-assisted ROM and weight-bearing activities as tolerance permitted.

The patient had an uneventful post-operative recuperation and was discharged to an acute rehabilitation facility for completion of her early therapy. She returned to her home at three weeks post-surgery, independent in ambulation and full weight bearing with a rolling walker. Rehabilitation continued, initially within the home, and then outside the home by 8 weeks post-surgery. Her limitations at that time were due to the mild equino-varus contracture of her contra-lateral foot and ankle. By 6 months post-TKR, the patient had achieved 10 – 130 degrees of right knee flexion, with no recurrence of her valgus deformity. (Figures 3 & 4) She was ambulatory in her neighborhood with a rolling walker and a splint on her left ankle. Within her home environment, she was able to negotiate short distances without use of a cane or walker.

 DISCUSSION

Soft tissues are extremely important for physiologic functioning of the knee joint.5Severe osteoarthrosis is often associated with deformity and compromise of normal soft tissues. TKR is a highly successful procedure for the relief of painful arthritis.1However, when attempting to restore function and correct abnormalities in ROM and alignment by TKR, it is imperative that attention be given not only to restoration of proper bony alignment, but even more importantly, to soft tissue balancing. Insufficient or incorrect soft tissue balancing may result in limitation in ROM, patellar mal-alignment, knee instability, pre-mature mechanical failure of the TKR components and pain.

Present day instrumentation for TKR offers many approaches for the correction of bony deformity: intra-medullary, extra-medullary guides, cutting blocks based on bony landmarks, computerized navigation, “customized” cutting guides fabricated based on pre-operative radiographic studies, and robotics.4,8 But none of these strategies offer a means to assure reproducible and accurate balancing of the soft tissue structures critical to optimal knee function.

The eLIBRA™ Soft Tissue Force Sensor is a newly developed instrument specifically designed to objectively address the challenge of achieving optimal ligament balancing in TKR. It may be an effective way to restore patello-femoral tracking while reducing the need for lateral release and compromise of the patellar retinaculum. This case report demonstrates the effectiveness of this tool in helping to accurately restore knee kinematics in a knee with significant fixed flexion and valgus deformities. The author has found it to be a very effective tool not only in helping surgeons to objectively assess their surgical technique but also in the training of orthopaedic surgeons to appreciate and achieve proper soft tissue balancing.

 REFERENCES

1. Insall J, Tria AJ, Scott WN. The total condylar knee prosthesis: The first 5 years. Clin Orthop Relat Res. 1979;(145)(145):68 – 77.

2. Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty. Clin Orthop Relat Res. 1985;(192)(192):13 – 22.

3. Sledge CB, Ewald FC. Total knee arthroplasty experience at
the robert breck brigham hospital. Clin Orthop Relat Res. 1979;(145)(145):78 – 84.

4. Laskin RS, Beksac B. Computer-assisted navigation in TKA: Where we are and where we are going. Clin Orthop Relat Res. 2006;452:127 – 131.

5. Griffin FM, Insall JN, Scuderi GR. Accuracy of soft tissue balancing in total knee arthroplasty. J Arthroplasty. 2000;15(8):970 – 973.

6. D’Lima DD, Patil S, Steklov N, Colwell CW,Jr. An ABJS best paper: Dynamic intraoperative ligament balancing for total knee arthroplasty. Clin Orthop Relat Res. 2007;463:208 – 212.

7. Picard F, Deakin AH, Clarke JV, Dillon JM, Gregori A. Using navigation intraoperative measurements narrows range of outcomes in TKA. Clin Orthop Relat Res. 2007;463:50 – 57.

8. Saragaglia D, Chaussard C, Rubens-Duval B. Navigation as a predictor of soft tissue release during 90 cases of computer-assisted total knee arthroplasty. Orthopedics. 2006;29(10 Suppl):S137 – 8.

9. Viskontas DG, Skrinskas TV, Johnson JA, King GJ, Winemaker MJ, Chess DG. Computer-assisted gap equalization in total knee arthroplasty. J Arthroplasty. 2007;22(3):334 – 342.

Optimal Bone Saw Blade Design

[Note:  This article was initially published in Medco Forum, Volume II, Number 5.  It is being republished with permission from Medco Forum.]

All surgical oscillating blades are not created equal.  There may be many similarities between blades, but the performance characteristics can be significantly different.  Orthopaedic surgeons require a reliable, effective means of making bone resections that enhance surgical control with the same feel every time.  As less-invasive reconstructive procedures evolve and biologic fixation advances, surgeons will need bone resection technology to minimize the possibility of injuring surrounding soft tissue structures as well as the living bone supporting the implants.  Synvasive Technology Inc.’s STABLECUT oscillating blade technology represents a substantial breakthrough in the science of powered bone resection.  STABLECUT is favored by reconstructive knee surgeons as a means of transforming the function of an oscillating blade from an “attachment” into a reconstructive tool, aimed at improving the surgical control of bone removal required to resurface an articulating joint.

Traditional oscillating blades have their teeth oriented on an arc, and when cutting bone, all of the teeth engage at once as the blade progresses and swings through its constantly reversing arc of motion.  This arc-shaped engagement, accentuated by the oscillating motion of the powered hand-piece, creates two primary influences that adversely affect performance.  First, as the blade direction is changed, the contact point of the teeth moves off center.  This reduces hand-piece control as the blade reacts to off-center contact, causing it to deflect right or left of the surgeon’s intended path.  Secondly, the resection path becomes matched to the arc-shaped excursion, preventing the teeth from effectively evacuating bone chips, which build up in front of the advance blade and generate friction.  This limits debris removal and increases both deflection and heat transferred to the adjacent bone tissue, increasing the potential risk cell damage and necrosis can pose to bone healing and biologic fixation.  All of these effects collectively raise the risk of collateral soft-tissue damage and inaccurate cuts.

The patented perpendicular (90 degree) teeth configuration on a STABLECUT blade establishes a centered back-and-forth sawing action within the fixed arc of powered oscillation.  It creates a stabilizing “high spot” in the center of the cut as the blade engages the bone.  This “high spot” makes the blade exceptionally stable, enabling the surgeon to achieve a higher level of precision as the controlled blade advances through a cut and around soft-tissue structures.  Debris is also ejected more efficiently, creating less friction, to enhance tissue care surrounding a resection.  Anthony K. Hedley, MD, Chairman of Orthopaedic Surgery, St. Luke’s Hospital (Phoenix, AZ), uses STABLECUT blades exclusively.  Dr. Hedley finds that “the STABLECUT blades are well designed in terms of tooth design, which provides for very precise cuts.  When a total knee replacement procedure is performed, it is important to use a straight blad that had no arc, so as to avoid loss of control when making cuts.  STABLECUT blades help avoid dimensional changes to the template bone that result in loose fitting components.  This is especially important when implanting press fit prostheses.”

Directional control and reduced temperature are important enablers of MIS total and unicompartmental knee replacement.  Stability of the saw blade greatly improves safety and precision as surgical exposures are reduced.  According to David Dalury, MD, of St. Joseph’s Hospital (Towson, MD), “I am impressed with the reproducibility and accuracy of STABLECUT.  These blades give me the confidence that I will be able to resect the template bone accurately during bone-conserving unicompartmental procedures.  The fact that you can be more precise in cuts means that you will be less likely to damage surrounding tissues – a definite enhancement in patient safety.”

STABLECUT bone resection technology is advancing reconstructive surgery today and will continue into the future as the interest in reduced-exposure reconstructions increases.  The inherent accuracy of STABLECUT technology will be particularly evident as computer-aided reconstructions grow.  STABLECUT blades maintain better directional control during the cutting process and are less likely to “kick-out” of the intended track.  The net benefit is a more accurate cut with less buildup of heat, to improve tissue care.  According to Mike Fisher, President and CEO of Synvasive Technology, Inc., “Our surgeon customers didn’t ask us to reinvent the powered oscillating hand-piece, rather to enhance the blade’s cutting performance and improve their confidence in the OR.”

Since its founding in 1990, Synvasive Technology, Inc. has steadily grown to become one of the most innovative leaders in orthopaedic resection technology.  Synvasive develops, manufactures, and distributes patented and proprietary instruments with a vision to advance and enhance the success of reconstructive procedures.  The company operates in accordance with the ISO 13485 quality management system and European medical device directive.  Synvasive’s products are marketed through a worldwide network of distributors and major orthopaedic companies, as well as a professional team of internal sales and customer service representatives.

Medco Forum® is a registered trademark of Medco Communications LLP, Evergreen, CO.

Lumbar Spinal Fusion Procedures: The Last 100 years

by Richard J. Nasca M.D.

Spinal fusion procedures are indicated for various disorders, deformities and injuries of the lumbar spine. The Albee and Hibb’s fusions for progressive deformities due to tuberculosis were performed in the early 1900’s. The anterior and posterior Interbody fusion techniques were popularized in the 1940’s and 1950’s. The Harrington rod for correction of scoliosis was a milestone invention which was poorly received by the orthopaedic community in the 1950’s. Pedicle screw fixation popularized in Europe was introduced in the US in the early 1980’s and meet with a great deal of resistance and skepticism from both neurosurgical and orthopaedic surgeons. In addition, a great deal of litigation was generated by some poor patient outcomes and a consortium of Philadelphia based plaintiff’s attorneys. In the mid 1980’s, metallic interbody cages were developed to stabilize the spine and contain the bone grafts used for fusion. In the late 1990’s percutaneous approaches to performing spine fusions and inserting spine fixation devices were developed. Modifications in the posterior interbody approach of Paul Cloward were made by Jurgen Harms. His method referred to as a transforaminal lumbar interbody fusion (TLIF) required facet joint removal and distraction to facilitate access into the disc space for the placement of bone grafts with titanium cages.

Shortly after the turn of the century a less invasive approach to the lumbar spine called an extreme lateral interbody fusion (XLIF) was described by Ozgur, Aryan, Pimenta and Taylor. This approach allows access to the lateral spine thru a small incision in the flank for insertion of cages and spine fixation. The L5-S1 level is not accessible with the XLIF technique.

Andrew Cragg, an interventional radiologist described an axial presacral approach to the sacrum in 2004. The AxiaLIF rod and instrumentation were developed by TranS1, Wilmington, NC. This technique provides access to the L5- S1 disc for interbody fusion by an axial portal drilled through the sacrum. After removal of the disc remnants, the end plates are prepared with Nitinal cutters. Bone grafts from the reamings and bone extenders are used to promote the interbody fusion. The AxiaLIF rod is used to stabilize the L5-S1 segment after preparing an axial tract in L5. The procedure has been used in patients with spondylolisthesis, spinal stenosis, degenerative disc disease and its variants, lumbosacral scoliosis as an anchor across L5 –S1 to enhance stability for fusion in long constructs, herniated nucleus pulposus and revision surgery. Pedicle and/or facet screws are used to supplement the fixation.

Although the AxiaLIF approach and method of preparing the disc space for interbody fusion has generated skepticism ,the results from the procedure are  encouraging with fusion rates of 90+%, complications of less than 1%, lessened hospital stay, blood loss and operative time when compared with more traditional interbody fusion techniques.

Dr. Nasca is a retired orthopaedic surgeon who specialized in surgery of the spine and who is a Medical Advisor to TranS1 and an advocate of Orthopaedic List .com

Accepting the Risks in Medical Education and Medical Practice

by Douglas Dirschl, MD

In a March 17, 2009 article in the New York Times, Dr. Richard Friedman, a professor of psychiatry at Weill Cornell Medical College, discusses the nearly universal preference patients have for a seasoned physicians over residents or physicians just out of training.  The strong perception is that physicians learn from experience, implying that the “practice” of medicine is just that – a process of continual learning and improvement.

How does one learn in medicine? Clearly, one large component has been intensive exposure to medical practice within the supervision of residency training programs.  Dr. Friedman points out to us, however, that there may be an inherent conflict at the heart of medical training: “what may be best for making a skilled, independent-thinking doctor may not always be best for patient comfort or safety”. We want our young physicians to be competent, knowledgeable, and confident, yet we also have a responsibility (and increasing scrutiny from regulatory and legal agencies) in protecting patients from the medical errors that could result from a physician’s inexperience.

All residents, at some point, leave the relative security of training and go out on their own. Some experts are now questioning whether medical training programs are striking the right balance between education and training and patient safety to produce physicians who can function optimally. Dr. Friedman argues that restrictions imposed by resident duty hour limitations, decreasing amounts of resident autonomy due to concerns of patient safety, and regulatory groups mandating that some medical complications should never occur, have combined to create a generation of young physicians who lack confidence in their ability to make judgments about patient care. In the pursuit of patient safety, we now deliberately prevent residents from acting independently on their own judgment in situations where a patient poses a theoretical risk.

It is said that 90% of orthopaedic residents currently go on to do fellowship training after residency. Is this because orthopaedics has become so highly complex that 5 years is not sufficient time to master it all, is it that residents completing programs today have less self confidence in their own abilities than the generation of physicians before them, or is it that society expectations have increased and it now expects ‘perfection’ of every physician, no matter how experienced. The answer is probably “yes, yes, and yes”.

To date, there are no reliable national data that regulatory changes in resident work hours, patient safety initiatives, or ‘never events’ (for example, CMS has determined that no patient should have a DVT after an orthopaedic procedure, and won’t pay for it if a patient does), have had a significant impact on preventable medical error or patient mortality rates. There is a cost to the development of professional identity of young doctors, arguing that it is hard to feel confident and independent unless you are given ample opportunity to stand on your own — and risk making a mistake.

There is no doubt that all physicians in training – and those in practice as well – pose an inherent risk to patients.  We should do everything we can to minimize this risk but recognize that doing so will probably impair physicians’ self-confidence.  We may end up with a generation of physicians who, by virtue of the environment in which they have trained, are more hesitant, more uncertain, and less self-confident that the American public might like.

Click here to read the full text of Dr. Friedman’s article.

Dr. Douglas R. Dirschl is Frank C. Wilson Distinguished Professor and Chair of Orthopaedics at UNC School of Medicine. He also serves on the Own the BoneSteering Committee and chairs the Critical Issues Committee for the American Orthopaedic Association.

Politics 101 for Orthopods

by Alan S. Routman, MD

If you ever get the chance, stop and take a look around at the way you practice orthopaedic surgery these days.  Certainly we have much better tools, devices, and technology than any of us ever imagined when we began our training years ago.  Some of these have improved patient outcomes, and some maybe not, but that’s a discussion for another day.

I’m thinking more of the government intrusion, the ever growing wedge that is being driven between us and our patients, and is radically shifting the landscape of our day to day practice.  Some guys simply dodge the oncoming train, and become employees of hospitals and multi-specialty groups and depend on practice administrators to steer them through the maze of new and burgeoning regulation.  The rest of us, in private practice, solo, or small groups, have to wonder if we can actually keep up with all the new rules and continue to maintain our medical lives the way we would like it to be.  Personally, I’m a patient oriented guy and can’t stand the thought of looking at an EMR on a computer screen instead of looking my patient in the eye.

This all brings me to the fact that our profession as orthopaedic surgeons is really worth fighting for.  Our training and skills, and what we can deliver to people in the ER, the OR, and in the office is truly wonderful.  And most of the time it’s fun, except when the paperwork and the intrusions drag us down and take us away from our work.

Remarkably, these are all the reasons why I believe it is incumbent on us, as surgeons, to take our message about patient care to the people who make the decisions that control our profession.  Those people are the politicians, and they know little to nothing about the practice of medicine.  We have to teach them.

Politics is a necrotic component of our society that seems to be completely devoid of any real knowledge or expertise about which many of the laws are made that govern us.  In medicine, this is having disastrous consequences and requires our immediate attention.  If we cannot educate and influence the people making laws, then we will (soon) witness the demise of the practice of medicine as we know it.  It is happening now, and not only in medicine.

I submit that my time can be better spent doing other things, based on my training and experience as a surgeon.  Unfortunately, I cannot afford to be a spectator to the debacle that is occurring before my own eyes.  If we do not act as a profession to stop this trend, then we too are guilty of the same negligence as the politicians.

Political advocacy is distasteful for many physicians, but, the practice of medicine is like a form of freedom. It may not be appreciated until it’s gone.  I write this to encourage all of my colleagues to consider political activism as important as anything else that one can do in their professional lives.  Forces are in place that will make physicians mere tools in the coming medical-industrial triangle of insurers, hospitals, and pharmaceutical giants.  Historically, those guys know how to play politics, and we don’t, and guess who the politicians are listening to.

Even if political involvement is personally distasteful, all of us can participate by speaking the language of politics, i.e., money.  Even if you can’t develop personal relationships with your local elected officials, you can still be a player by becoming an active member of your state and federal orthopaedic PACs, and also helping out when one of your colleagues asks for a check for a medicine friendly candidate running for office.  Don’t just walk away when you have the opportunity to support other surgeons who are working hard to make a difference in your profession.  Think in terms of making a major commitment, just like our competitors do, in your political involvement.  Checks for candidates at $500 are baseline, and $1000 annual contributions to your AAOS PAC (think Stu Weinstein) should be as automatic as paying the mortgage.  If you sit on the med exec committee of your hospital, you can play a huge role by ensuring its participation in political fundraising using those available (and painless) staff dollars.

Percentage of participation by orthopaedic surgeons is increasing, but is still miniscule compared to attorneys, chiropractors, podiatrists, and the like.  We have everything to lose, and they have everything to gain by the changing political landscape.  Together we can preserve and protect our profession.  Get off your financial butt, and develop a passion for the rising tide of physician advocacy.  Together we can have the influence and power that will make a difference in the evolving healthcare debate.  We need you to be on the team and play this important role in the fight for our future.

Dr. Routman is an orthopaedic surgeon in Fort Lauderdale, FL.  He has been President of the Florida Orthopaedic Society and a member of the Board of Councilors of the American Academy of Orthopaedic Surgeons.  He is currently the Vice Chairman of the Broward County Health Facilities Authority Board, on the Board of Governors of the Florida Medical Association, and is the Vice Chairman of the Florida Medical Association Council on Legislation.

True Success

by Tom Morris

From Plato and Aristotle to the present day, the wisest people who have ever thought about challenge and achievement in our lives and work have left us bits and pieces of powerful advice for attaining true success in anything we do. I’ve put these ideas together in a simple framework of seven universal conditions. Let me lay them out briefly and then we’ll look at each. Whether you apply them in your practice, in your life, or teach them to your patients, they can be very helpful for focusing on what it takes to reach important goals.

The 7 Cs of Success

For the most deeply satisfying and sustainable forms of success, we need to bring into any challenge, opportunity, or relationship:

(1) A clear CONCEPTION of what we want, a vivid vision, a goal clearly imagined.

(2) A strong CONFIDENCE that we can attain that goal.

(3) A focused CONCENTRATION on what it takes to reach the goal.

(4) A stubborn CONSISTENCY in pursuing our vision.

(5) An emotional COMMITMENT to the importance of what we’re doing.

(6) A good CHARACTER to guide us and keep us on a proper course.

(7) A CAPACITY TO ENJOY the process along the way.

There are certainly other concepts often associated with success, but every other one is just a version or application of one of these in specific situations. The 7 Cs give us the most universal, logical, and comprehensive framework for success.

(1) A clear CONCEPTION of what we want, a vivid vision, a goal clearly imagined.

In any facet of our lives, we need to think through as clearly as possible what we want to accomplish. True success starts with an inner vision, however incomplete it might be. The world as we find it is just the raw material for what we can make it. We are meant to be artists with our energies and our lives. And the only way to do that well is to structure our actions around clear goals.

(2) A strong CONFIDENCE that we can attain the goal.

Inner attitude is a key to outer results. Philosopher William James learned from championship athletes that a proper confidence should be operative in all our lives. In any new enterprise, we need upfront faith in what we’re doing. Sometimes we may have to work hard to generate this attitude. But it’s worth the work it takes, because it raises our prospects for success. The best confidence arises out of competence and then augments it.  It’s of course no guarantee of success. But it is among the chief contributors to it.

(3) A focused CONCENTRATION on what it takes to reach the goal.

Big dreams just lead to big disappointments when people don’t learn how to chart their way forward. Success at anything challenging comes from planning your path and then putting that plan into action. Gestalt psychologists teach us that a new mental focus generates new perceptual abilities. Concentrating your thought and energy in a new direction, toward a clear goal, you begin to see things that you might have missed before, that relate to the goal you’ve set. This focus allows you to plan and act, and adjust along the way. Even a flawed plan can start you off and lead you to where you can discover a better one. A focused concentration of thought and action is key.

(4) A stubborn CONSISTENCY in pursuing our vision.

The word ‘consistency’ comes from two Greek roots, a verb meaning “to stand” and a particle meaning “together.” Consistency is all about standing together. Do my actions stand together with my words? Do my reactions and emotions stand together with my deepest beliefs and values? Do the people I work with stand together? This is what consistency is all about. It’s a matter of unifying your energy and efforts in a single direction. Inconsistency defuses power. Consistency moves us toward our goals.

(5) An emotional COMMITMENT to the importance of what we’re doing.

Passion is the core of extraordinary success. It’s a key to overcoming difficulties, seizing opportunities, and getting other people excited about your projects. Too much goal setting in the modern world has been an exercise of the intellect and not also of the heart. Philosophers appreciate the role of rationality in human life. But we know that it’s not just the head, but also the heart, that can guide us on to the tasks right for us, and keep us functioning at the peak of our abilities.

(6) A good CHARACTER to guide us and keep us on a proper course.

Character inspires trust. And trust is necessary for people to work together well. Good character is required for great collaboration. In a world in which innovative partnerships and collaborative synergies are increasingly important, the moral foundation for working well together matters more than ever before. And good character does a lot more than just provide for trust. It has an effect on each individual’s own freedom and insight. Bad character not only corrupts, it blinds. A person whose perspective has been deeply skewed by selfishness or mendacity cannot understand the world in as perceptive a way as someone whose sensibilities are ethically well formed. Good character makes sustainable success more likely.

(7) A CAPACITY TO ENJOY the process along the way.

The more you can enjoy the process of what you’re doing, the better the results tend to be. It’s easier to set creative goals. Confidence will come more naturally. Your concentration can seem effortless. Consistency will not be a battle. The emotional commitment will flow. And issues of character will not be as difficult to manage. A capacity to enjoy the process is entwined with every other facilitator of success in a great many ways.

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These conditions of success are all deeply connected. They constitute a unified framework of tools with which we can work our way toward the most fulfilling forms of achievement. They will help us to make our proper mark in the world. They will move us in the direction of true success. And why should we ever settle for anything less?

Tom Morris is the author of such books as True Success, The Art of Achievement, If Aristotle Ran General Motors, and If Harry Potter Ran General Electric. He writes weekly for The Huffington Post and can be found philosophizing on Twitter as TomVMorris.  He can be reached at TomVMorris@aol.com or through the Morris Institute.

Dr. Morris was kind enough to guest author this article for OrthopaedicLIST.com.

The Prayer of a Surgeon Emeritus

by Howard H. Steel, MD

Lord, Thou knowest I am growing older.

Keep me from becoming talkative and possessed with the idea that I must express myself on every subject.

Release me from the craving to straighten out everyone’s affairs.

Keep me from the recital of endless detail.  Give me wings to get to the point.

Seal my lips when I am inclined to tell of my aches and pains.  They are increasing with the years, and my love to speak of them grows sweeter as time goes by.

Teach me the glorious lesson that occasionally I may be wrong.

Make me thoughtful but not nosy, helpful but not bossy.  With my vast store of wisdom and experience, it does seem a pity not to use it all, 

but Thou knowest, Lord, that I want a few friends at the end.

 [Published with permission from Dr. Steel.]

Howard Steel, MD is an icon in Orthopaedics and his inspiration goes beyond Orthopaedics.   Clinically he dedicated his career to children at Temple and the Shriners.  Educationally, he taught thousands of residents, medical students and junior faculty about surgery and life.  In 1970, he founded the Eastern Orthopaedic Association and was the Society President for the first two years.  He has hardly missed a meeting since.  Recognizing there is more to life than medicine, Dr. Steel donated funding (30+ years) for a “non-Orthopaedic” lectureship for many of the regional orthopaedic societies, the AOA and other orthopaedic entities.   Howard is funny, fun-loving and bigger than life.  

Comments about Dr. Steel by Judith F. Baumhauer, MD MPH, University of Rochester School of Medicine and Dentistry