Author Archives: James Hundley, MD

About James Hundley, MD

Dr. Hundley is a retired orthopaedic surgeon and the originator and co-founder of OrthopaedicLIST.com, a resource website for orthopaedic surgeons and related professionals.

Our Beloved but Challenged Profession of Orthopaedic Surgery

by Augusto Sarmiento, MD

The metamorphosis of our profession over the last several decades prompted me to publish an article in the January/February 2015 issue of Current Orthopaedic Practice. Following is a summary of that article:   

The spectacular growth of Orthopaedics in recent decades has primarily been due to mostly-beneficial technical innovations. Much of this growth, however, is threatening our historically high professional standards.

As modern orthopaedics is based mostly on surgical treatments, the teachings of biological foundations have taken a back seat. Thus, the orthopaedist of today is evolving into a “cosmetic surgeon of the skeleton” rather than a surgeon/scientist.

Our orthopaedic discipline has fragmented into sub-specialties. This fragmentation creates problems, particularly in smaller communities where orthopaedists should be prepared to treat most orthopaedic conditions.

Chiropractors, osteopaths, nurse practitioners, and operating room technicians are responding to the impending orthopaedic crisis by seeking to expand their territories, allowing them to perform procedures long considered to be the exclusive domain of medical doctors. The State of Florida’s Health Care Force Innovation is considering a request from Nurse Practitioners to allow them to prescribe medications, including narcotics. In New Jersey, physician assistants with doctoral degrees are lobbying to carry out procedures long under the dominion of medical doctors.

The ongoing Justice Department investigation of what it has called ‘‘egregious unethical transactions’’ and a ‘‘corrupt relationship between industry and orthopaedics” has produced nothing.

We have failed to respond to the increasingly greater control of our destiny by industry, allowing it too much influence over the content of our continuing education and research.

Our discipline has established orthopaedic guidelines, which will encourage complacency by pushing practitioners to accept without question their recommendations. Fear of litigation arising from failing to follow the guidelines will inhibit new ideas and treatments and reinforce the herd mentality.

A number of nations and empires, no matter how powerful and solid they seemed to be, failed not from invasions but from suicide. This could be the ultimate fate of our profession, which is experiencing major changes.  It is our responsibility to resolutely address the challenges that these changes present.

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and Past-President of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.

Finally: Category 1 CME’s for Literature Research!

by James D. Hundley, MD

It’s about time!   Finally, orthopaedic surgeons and other physicians can get Category 1 CME’s for doing literature research.    Not only does that help you but it helps your patients.  Heretofore it has been that you could do your reading and get Category 2 CME’s, but not Category 1.

Who’s to say that it’s better to sit in a lecture at an accredited meeting than to study a peer-reviewed article in a respected journal?  Not only does this let orthopaedic surgeons and others get the CME’s that they need for licensure and hospital privileges but it let’s them do it when they need it, on their own time, about a subject of current interest, and economically to boot.

What else needs to be said?  It’s available at for[CME].  Check it out for yourself.

Dr. Hundley is a retired orthopaedic surgeon and founder and president of OrthopaedicLIST.com.

States Should License Orthopaedic Assistants

by James D. Hundley, MD

A Case for Encouraging, not Discouraging, Orthopaedic Assistants

            A wise person has been quoted as saying, “For every action there is a good reason and then there is the real reason.”  I wonder if something like that that may apply to the position being taken by the American Academy of Physician Assistants (AAPA) in regards to the American Society of Orthopaedic Assistants (ASOA).  As I understand it, the AAPA has taken a position opposing the licensing of Orthopaedic Assistants based on brand infringement and an inadequate knowledge base.  Is it really about patient care or is it about turf protection?

In the first case, the ASOA has conceded the use of the word “Physician” in the name of their organization.  They are no longer the American Society of Orthopaedic Physician Assistants but are now the American Society of Orthopaedic Assistants.  Thus, that argument has become moot.  If there is an argument against their knowledge, based on my my long-term experience with an Orthopaedic Physician Assistant (OPA) and many years as a member of the National Board for Certification of Orthopaedic Physician Assistants I beg to differ.

The OPA with whom I worked for over thirty years was highly knowledgeable and served as a valuable member of our team.  His services in the operating room, the hospital, and the office were invaluable.  He not only made me more efficient, he made me better, which allowed us to deliver better patient care.

My role on the National Board was helping to update the written certification examination every two years.  This process was directed by a nationally known, professional educator and performed by board certified Orthopaedic Physician Assistants and Board Certified Orthopaedic Surgeons.  The questions and answers were evidence-based, pertinent, and difficult.  As with other boards, candidates were required to have a certain amount of experience before being allowed to sit for the examination.  From my detailed review of the questions, both experience and appropriate education were required to pass it.

The issue that should be getting the attention of all medical organizations is the impending growth in medical manpower needs.  The population is aging; we hear that 10,000 Americans turn age 65 every day.  Population growth is outstripping the growth of medical providers.  Medical schools will not be able to keep up with the number of physicians needed.  New schools are being opened and old ones are expanding, but they simply cannot turn out enough additional physicians quickly enough.  I believe that the void will have to be filled with physician extenders.  The greatest numbers will be physician assistants and nurse practitioners but I believe that there will be an important role for trained orthopaedic assistants as well.

The roles will be different and physician assistants should well know that.  Their roles and, therefore their licenses, are different from physicians.  Orthopaedic assistants will have to perform within their licenses, too, and I believe that they are prepared to do so.

So why is it important for Orthopaedic Assistants to be licensed by their states?  Along with being certain that they are certified and qualified, the issue of payment is huge.  If they are not licensed, third party payers will not pay for their services.  That means that the surgeon would have to pay for the assistant out of the ever-diminishing compensation he receives for a surgical case.  Alternatively, he could use another surgeon as an assistant a level of compensation higher than an OA.  Thus the surgeon is incentivized to involve another surgeon in his case at a greater cost to the system and at reduced efficiency; the other surgeon should be treating his own patients.  If an OA can assist just as well (often better in my experience) the above arrangement makes absolutely no sense.

My message is simple:  Stop obstructing the licensing of Orthopaedic Assistants.  Encourage it!  There is plenty of work to go around now and there will be more in the future.  Our medical system will need all of the help it can get.  We need highly trained Orthopaedic Assistants and they need to be licensed and adequately compensated.

Dr. Hundley is a retired orthopaedic surgeon and a founder and the president of OrthopaedicLIST.com.

Corn Pickers, Murdercycles, and Plane Crashes

by James D. Hundley, MD

Part I:  The Farmer and the Corn Picker

My training and early experience after medical school entailed an internship at a large university medical center followed by five years of residency at an even larger university medical center.  I then served as an orthopaedic surgeon at a referral hospital in the U.S. Air Force.  Although I knew better, you might have thought that I’d “seen it all” by the time I joined the Wilmington Orthopaedic Group in 1975.  I hadn’t.

My first weekend on call was not memorable other than being so easy.  I guess that I “rounded” on the patients of our group who were in the hospital and took care of some relatively minor injuries, but that would have been it.  “Ah ha”, I remember.  This is going to be easy:  Work during the day; get an afternoon off every week.  Take emergency call only a fourth of the nights and a fourth of the weekends.  Before it had been every second.  Wow!

“Wow!” was right.  That party ended my second weekend on call. Friday after evening rounds I was walking through the physicians’ lounge on my way home and almost passed by general and thoracic surgeon Dr. Ellis Tinsley who had one hand on the telephone and one held out for me to stop.  He had been talking to someone in the emergency department (ED) in Burgaw who had just sent a man who had fallen into a corn picker our way.

Now I’ve never seen a corn picker up close, but it was described as a large farm machine that is driven through cornfields pulling up corn stalks and feeding them into an auger.  The auger is a screw-like device used to pull through the stalks leaving behind the ears of corn.  It hurts to imagine what it would do to a human leg.

Imagine the unimaginable.  A highway patrolman was cruising a backcountry road and saw a man in distress.  He turned off the machine and called for help.  The rescue squad took the man to the ED in Burgaw where he was stabilized and transported to the New Hanover Regional Medical Center in Wilmington.

Ellis alerted the operating room staff to be prepared; no way could we have managed something of this magnitude in the ED.  Then we changed into our green “scrubs” and went to the ED to meet the ambulance.

The patient arrived in fairly good condition and was taken directly to the operating room (OR) where an anesthesiologist put him to sleep and began pushing intravenous fluids and blood (O-negative until we could determine a blood type) as samples were being taken for a variety of lab studies.

We found that the area of trauma was “limited” to his lower extremities and pelvic area.  One lower extremity was absent as were his genitalia.   The lower half of his bladder was exposed and distended.  Much of the buttocks on the other side had been chewed away exposing but not injuring the sciatic nerve.  Altogether he had a huge open wound involving about two-thirds of the bottom of his trunk.

Because we could not find the urethra (opening in the bladder through which urine normally drains and through which to insert a catheter), we called in urologist Dr. John Cashman.  He couldn’t find it either, so he had to make an incision in the bladder through which to insert a catheter.  Although he had no other choice that proved troublesome in that there was constant urinary leakage around the catheter thereafter, not helpful in trying to develop a clean and dry wound. Later we needed a plastic surgeon to cover the wounds and called in Dr. Ed Wells who did wonderful work as well.

Ellis had taken charge of the patient from the beginning and did a masterful job of pulling him through.  There were many days in the ICU managing pain, electrolytes, blood counts, and infection but ultimately the patient survived and healed his wounds.  My role after many hours that Friday night was joining Ellis and the other surgeons in the OR to debride dead tissues and clean the wound which we did on that Saturday and Sunday and many days after.  John diverted the urine and Ed grafted skin and ultimately all of the wounds healed.

The patient learned to walk on crutches and could even drive his pickup truck so we felt like we had done a pretty good job.  Sadly, however, he reportedly committed suicide a couple of years later.

Memory of that suicide brings to mind Ellis’ response to someone who asked why we would work so hard to save someone so badly mangled.  Ellis’ replied, “It’s up to us to do what we can.  It’s up to God to decide who lives and dies.”

That pretty much filled up the Friday night of my second weekend on call in Wilmington.  I breathed a sigh of relief when I finally got home and went to bed.  Based on my prior experience, the hard part was over.

Part II:  The Murdercyclist and “Honey, There’s been a plane crash!  They want you back at the hospital.”

Saturday morning, the next day of my second call weekend in Wilmington, was uneventful.  I had a leisurely breakfast and visited with my wife Linda who was eight months pregnant at the time and our two young children.  Then I headed over to the hospital for rounds.  About mid-morning I was called to the ED for a young man who had crashed his motorcycle.

Many who treat trauma patients call motorcycles “murdercycles” because of what happens to their riders.  Murdercyclists don’t seem too concerned, however, and even insist that they are safe to ride even without helmets.  They blame accidents on automobile drivers who fail to see motorcycles.  This fellow was in a single vehicle crash of his own causing.  Sorry about digressing.  I can’t help it.

At any rate, he had three open wounds involving fractures and joints, all requiring hours in the OR cleaning up and fixing things.  Fortunately I had my friend and outstanding Orthopaedic Physician Assistant Deak Walden by my side, and we finished about suppertime.  I guess that fellow did OK as I remember little else about the case.  That’s typical, by the way.  When people do well you typically forget the case and move on unless something like writing this story triggers a memory.

I went home.  As I was getting out of my car, my five-year old son was so excited to tell me that his beloved grandparents had come to see us that he tried to pop open our storm door by running into the glass panel.  The door didn’t open and his hands went through the glass cutting one of them, fortunately not too badly.  That was managed with first aid by my neighbor and partner Dr. Charlie Nance, but the vision of those little hands going through that glass window still shocks my psyche.  I guess I emotionally settled for a few seconds and started over to see how badly he was hurt.

Before I had taken a couple of steps Linda came out with the phone in her hand saying, “Honey, There has been a plane crash!  They want you back at the hospital.”

“Very funny”, I responded.  She wasn’t joking.

Professional wrestling was just becoming popular in 1975.  Wrestlers traveled together and performed in the smaller markets.  Charlotte, Charleston, Raleigh, and Wilmington come to mind.  This group was flying a small charter up from Charleston for a Saturday night performance at Legion Stadium.

The emergency call schedule for orthopaedic and neurological surgeons in 1975 worked like this:  If a patient in the ED needed a specialist and knew which doctor he/she wanted, the ED would call that specialist.  If the patient did not know whom to call, the ED would call whoever was on “unassigned call” (ortho for ortho; neuro for neuro).  In our group, we took turns covering the weekends Friday through Sunday, which included some days and nights of responsibility for “unassigned” patients.

There was a lot of crossover among specialists.  Orthopaedic surgeons, plastic surgeons and some general surgeons treated hand injuries, for example.  In the case of spine injuries without neurologic impairment, orthopaedic surgeons took them.  If there were neurologic impairment, the neurosurgeon would be the primary physician.  We consulted back and forth but that was how the “admitting physician” for that patient was determined.  I was on unassigned call that Saturday.

When I walked into the New Hanover ED, there was more commotion than I had seen before.  Lying on gurneys were the three largest men I had ever seen.  One had a compressed fracture of the seventh thoracic vertebra (T7) with no neurologic deficit.  One had an “explosion” fracture of the second lumbar vertebra (L2) with no neurologic deficit; one had an “explosion” fracture of the first lumbar vertebra  (L1) and was paraplegic (“paralyzed from the waist down”).  They had no other serious injuries.

The neurosurgeon on unassigned call and I arrived about the same time.  He made it clear that he did not want to be the primary physician for any, and for reasons I’ve never understood tried very hard to convince me to perform a decompression laminectomy on the one who was paralyzed.  Fortunately I had been trained too well to be so inclined, and my resolve had been reinforced by a recent authoritative review of the treatment of spine injuries by Howorth in The Journal of Bone and Joint Surgery.  Dr. Howorth made it clear that emergency decompression surgery for fractures had no favorable effect on paralysis.  The damage to the spinal cord had been done.  Emergency surgery could make the patient’s condition worse but not better.  I agreed to manage the patient but not to operate.

As those were the days before much surgical stabilization of spinal fractures, the treatment was keeping the patient horizontal and trying to avoid or worsen injury to the spinal cord.  The next biggest worry was bedsores from lying on their backs and a turning bed was available to strap the patient between two frames and allow the nursing staff to flip him from supine to prone every two hours.  When the flip had been accomplished, the then top frame was removed to allow the tissues on the top to be decompressed, inspected, and cleansed.

Guess what?  These guys were way too big for this frame.  Now what?

By then, Deak had arrived and we decided that the patients needed plaster “turtle” shells for turning while protecting their spines.  Deak made interlocking half-shells that would protect the spine when strapped together for each patient.  Once the patient had been logrolled from front to back and so on, the top shell could be removed for the purposes noted above.

The next challenge was how to perform 180-degree turns on men weighing 240+ pounds.  The solution came from the hospital maintenance staff who used plywood boards to widen the single sized hospital beds and placed double sized mattresses on them.  Then the nursing staff could logroll the patients from prone to supine and back again without having to lift them.  That worked and they got no pressure sores.  We were not much attuned to DVT (deep vein thrombosis) during those days, but fortunately they had no apparent DVT’s or pulmonary emboli.

So how did they do?

Patient 1:  L1 fracture with paralysis.  He and his family were obviously distraught about his condition and concerned that the neurosurgeon was not board certified.  They requested consultation from Dr. Guy Odom, Chairman of the Duke Department of Neurosurgery.  Dr. Odom chartered a twin-engine airplane with two pilots at the patient’s expense and came for a visit.  He reviewed the x-rays and examined the patient and told him that his treatment was appropriate.  I don’t know how the patient felt, but I felt both relief and validation.  Dr. Odom returned to Durham.

After about a week the patient was flown to Houston by charter airplane for continued treatment.  I heard through the grapevine that he had surgery there and was told that had they gotten to him sooner they could have helped his paralysis.  My take is that they felt badly about doing surgery not likely to help him and used that as an excuse.  At any rate, I never heard from him again.

Patient 2:  L2 fracture with no neurologic deficit and who was a former professional football lineman.  He had no complications and he flew home to San Diego.  I heard that he did well, but do not think that he returned to wrestling.

Patient 3:  Thoracic compression fracture; interesting fellow who was loaded with personality.  He fully recovered, became a World Champion professional wrestler, and remains famous to this day.

A few months after he was discharged, he called to say that he was coming to Wilmington and asked if he could come see me at home.  We welcomed him and he and an even larger fellow arrived that evening in a Buick Rivera bristling with antennas.  They came into our home, and he lay down on the floor and played with our young children, an action distinct from his professional persona.  He sent greetings through our mayor a year ago and just recently a friend showed me a photo that he had taken of him taken sometime in November.

Other recollections about this case:

  1. Professional wrestling was much bigger than I realized, and these men were celebrities.  Hospital staff were often admonished for trying to sneak peeks through slightly opened doors, and we were often asked how they were doing.
  2. When other professional wrestlers came to visit them in the hospital they, too, were treated as celebrities.
  3. The pilot was killed in the crash ostensibly because the seat of the passenger behind him was torn from the floor of the plane and the wrestler’s body slammed the pilot’s head into the dashboard of the plane.
  4. The pilot’s family sued the airplane manufacturer because the seats were torn loose in the crash.
  5. Want to know why the plane crashed?  It was reported that when they loaded the plane in Charleston, the load was above the regulatory maximum.  The pilot had a simple solution.  He drained enough fuel from the plane’s tanks to get below the maximum allowable takeoff weight.  They ran out of fuel within sight of the airport and crashed into a pine forest.

Dr. Hundley is a retired orthopaedic surgeon and a founder and the president of OrthopaedicLIST.com.

 

How to Pick Your Surgeon, a Surgeon’s Perspective

by James D. Hundley, MD

 

As a physician and surgeon, I’m often asked who to choose to do someone’s surgery.  The frequency of these questions has grown since I retired from my orthopaedic practice.  I don’t have any advice about how to pick one’s primary care physician or internal medicine specialist but here’s what I think in terms of how to pick your surgeon.

There are a few ways that we as surgeons can evaluate our peers but in terms of technical abilities, we may not be the best judges.  Here’s where I think we can be useful:

1. Decision-making:  It’s extremely important to know not only how to operate but when to operate and when to not operate.  When we discuss cases with others and hear that they operated on someone we thought would be better treated non-surgically, we learn something important about them.  Likewise, when we think that they should operate but don’t, we have an opinion on that, too.

2. Second opinions:  We learn a lot about other surgeons when we see their patients for second opinions.  That’s a very small number, however, so it’s only a glimpse and not necessarily all that helpful.

3. Complications:  When surgeons’ patients have complications it’s not unusual for those patients to seek other surgeons for opinions and/or resolution of problems.  This is an opportunity to judge decision-making and technical performance.

As for technical expertise, however, you may want to look to someone other than a surgeon.  Although we see one another frequently in the corridors and locker rooms of the surgical suite, we don’t spend a lot of time watching others operate.  We’re busy doing our own work so we’re not necessarily the best critics of another’s skills.  That said, who do you ask?

Here’s my opinion:

1. Operating room nurses (actually the entire OR staff)

a. Pros:  They work in the OR day in and day out and get a broad exposure to surgeons.  They see how they prepare and how well they carry out their procedures.

b. Cons

i. People tend to be complimentary of those they like and/or treat them well and derogatory of those who treat them badly.  You’ll have to work your way through this to get a useful answer but the answer is there if you can tease it out.

ii. Questions like this really put them on the spot and some nurses may be reluctant to give you a specific answer.  Again, it’s up to your own communication skills to learn what you can.  Sometimes you’ll just have to move on and ask someone else.

2. Product representatives

a. Pros:  In orthopaedics especially, manufacturers’ representatives are often physically present during operations where their products are being used.  Thus, they likely observe as many or more different surgeons who use their products as anyone else.

b. Cons:  They are conflicted in that they want surgeons to use their products so they might be incented to recommend those who do.

3. Physical Therapists and Occupational Therapists

a. Pros:  Although they don’t see the operations themselves they see patients in objective ways such as how the incisions look after surgery and the stability and function of the replaced joint.

b. Cons:  None that I can think of unless they work for a particular surgeon or group and then they would at least have a theoretical conflict of interest.

4. Patients who have had surgery themselves and their families

a. Pros:  They have had surgery and thus experience with a surgeon.

b. Cons

i. Tunnel vision:  Unfortunately their opinions are based on a cohort (i.e. a group) of one (i.e. themselves) so if they did well they may be overly happy and if they did poorly they may be unjustifiably unhappy.

ii. Patient opinions can be heavily swayed by how kindly they perceive that they were treated by their physicians.  Thus, their opinions of the quality of their surgery can be swayed by that perception.

iii. Patient expectations are variable.  If they think they should be made “normal” by surgery they will be likely be disappointed.  Realistic expectations go a long way toward satisfaction in the outcome which goes a long way toward satisfaction with the surgeon.

iv. Rehabilitation is extremely important in orthopaedic surgery.  Highly motivated patients tend to do better than those who are passive and unwilling to do what it takes to make themselves better.  Rehab can be arduous and painful.  The ones who want their orthopaedic surgery to be a magic cure are likely to be disappointed.

Dr. Hundley is a retired orthopaedic surgeon, a founder and the president of OrthopaedicLIST.com, a free, open access, resource website for orthopaedic surgeons and related professionals.

Coccygodynia: Whatever Happened to Performing a Physical Examination?

by James D. Hundley, MD

            There are so many good things about Modern Medicine that I hate to be critical but the following story from one of my friends put a bee in my bonnet:

Dr. X is a retired university Professor of Sociology who is in great health with no known history of cancer or other serious disorder.  He reported that he fell onto his buttocks with a brief duration of tailbone pain several weeks before his office visit that was precipitated by having to sit in a confined space on an airplane for several hours during which he developed “tailbone” tenderness that occurred only when sitting.  He denied pain on lying supine, night pain, back pain, neurologic symptoms, bowel difficulties, and blood in his stools.

Because his tenderness persisted for a few weeks he made an appointment with a capable orthopaedic surgeon and was seen by the surgeon’s PA.  The PA took a history and then did a cursory examination reportedly checking the strength of the patient’s toes and ankles.  An x-ray was “normal”.  The PA ordered an MRI.

Coincidentally, my friend and I were scheduled for a lunch meeting between the office visit and the MRI at which he asked if I thought he needed to have the MRI.  After a discussion during which I did not feel that I could recommend against having the MRI he decided to proceed with it.  Not surprisingly, the MRI was negative.

Here’s the rub.  Why get an MRI before doing a thorough physical examination and using the history as a guide?  With a history like this, what was the PA looking for?  Cancer?  On what basis?

As for the physical exam, here’s what I think should be done:

  1. Examine the intergluteal crease over the sacrum and coccyx externally for visible skin changes and tenderness.  Is the problem really his tailbone?  What about a pilonidal abscess or cyst, for example?
  2. Perform a rectal examination to check for masses and tenderness of the coccyx which is easy to palpate.  Check the prostate and for occult blood.  How about a thrombosed or abscessed hemorrhoid?
  3. Do a back exam to see if this was referred pain.  That would include back tenderness and range of motion, nerve root irritation tests, and a neurologic exam (some of which the PA to his credit reportedly performed).
  4. Always remove shoes and stockings and check the ankles and feet for circulation and ulcerations, of course, not to diagnose tailbone tenderness but because you’re a thorough clinician and the opportunity to so is before you.

Assuming the findings of the exam were negative, how about some conservative treatment such as allowing time to recover and advice on how to manage his symptoms.  Since he only had pain on sitting, he didn’t really need analgesics or anti-inflammatory medications.  A simple pad with a cutout in the rear to unload the coccyx (not a “doughnut” which unloads the wrong area) should be very helpful.  Then check him back in a few weeks unless the symptoms have subsided spontaneously.

Interestingly, the patient reported that the tenderness subsided within a week or two after the MRI.  Did the MRI cure the problem?  Of course not.  Did peace of mind have anything to do with it?  Maybe, but he wasn’t very nervous about his condition to begin with and after we discussed his problem before the MRI he said he was even less worried about the basis for his symptom.

If we’re to do our share in reducing the cost of Medicine, we need to avoid unnecessary testing, especially those as expensive as MRI’s.

 

Dr. Hundley is a retired orthopaedic surgeon, a founder and currently the president of OrthopaedicLIST.com, a free, open access, resource website for orthopaedic surgeons and related professionals.

Welcome to the Newest OrthopaedicLIST.com!

March 12, 2014

Dear Ladies and Gentlemen,

Welcome to the newest version of OrthopaedicLIST.com.  This is our most comprehensive update since we launched in 2003.  We changed to offer new and improved services and sincerely hope that you like it.  We are the same people who have been supporting OrthopaedicLIST.com all along and are under the same ownership.  We just needed to make some changes to modernize the site.  Currently we’re focusing on being sure that our basic services are working properly.  New services will be rolled out in the near future.

Because of the huge size of this database making the change was a daunting process but our extraordinary IT folks persisted and as of yesterday afternoon it became available to you.  Among other things, you’ll find that the site is lighting fast and you can search for almost everything on the site from the search box on the home page.  If you want to be more specific, of course, you can go to the desired section for your search.

The search exception is if you want to search by manufacturer.  There you will need to roll your cursor over “Search Options” and then click on “Search by Manufacturer”.  That will take you to an alphabetized list of manufacturers from where you can select the one you want.

This has been an unbelievable process and will continue to grow and improve.  Many tweaks need to be made, but the information is there for you here and now.  If you need help, you can always “Ask Bones”.

Thank you for your support.  Please visit often, let your colleagues know about OrthopaedicLIST.com, and please let us hear from you at info@orthopaediclist.com.

Sincerely,

James D. Hundley, MD, President, OrthopaedicLIST.com

 

A Triumph of Matter over Mind

by Augusto Sarmiento, MD

January 25, 2014

The current pervasive and misguided infatuation with the idea that in the care of fractures it is indispensable to achieve perfect restoration of anatomy in all instances in order to obtain good clinical results continues to blind many in our profession. I have previously made reference to this obsession suggesting that we train our residents to be cosmetic surgeons of the skeleton rather than physicians/scientists1.

My belief that Orthopaedics is losing its scientific primacy and rapidly becoming an entirely technical discipline was reinforced a short time ago when I learned of a clinical situation where passion prevailed over reason with very likely adverse serious consequences.

The clinical case consisted of a 21 year old man who was involved in automobile accident rendering him paraplegic. In addition he had suffered bilateral comminuted, distal intraarticular fracture of both forearms. The fractures were treated by means of internal fixation using plates and screws as well as multiple pins that held together the diligently repositioned small fragment. Radiographs obtained following surgery demonstrating excellent reduction of the fractures.

For reasons not known to me, the surgeon chose to improve upon the fixation achieved from the plates and screws by placing on the dorsum of the patient’s right arm a long plate that extended from the neck of the third metacarpal to the mid-radius. Several screws filled the holes in the long plate. This plate, I was told, would be removed six weeks after surgery; therefore I assumed it was not intended to encourage fusion of the wrist.

I cannot express strong disagreement with the procedure performed for the care of the radius fractures that must have taken a great deal of time plus the likely possibility that the extensive dissection of the bony fragments could result in major stiffness of his wrists joints. After all this is the current party line. However, I cannot help but question the wisdom of inserting a plate that inevitably will increase the degree of limitation of motion of the wrist from which the patient will never completely recovered.

This very realistic scenario provokes an even greater discomfiture when one realizes that the young man was paraplegic and will remain paraplegic for the rest of his days. As such, his only mode of locomotion will be a wheel chair, from which he will transfer to his bed and automobiles. A bit of thought should have made the surgeon aware that transfer activities from a wheel chair require a significant degree of dorsiflexion of the wrists. In order to lift one’s body with the use of the hands, dorsiflexion of the wrists is essential. The young man, I anticipate, will not be able to do so, and if he masters s technique to accomplish the task it will be a very complicated and difficult one.

I have surmised that the surgeon performing the surgery was very likely a technically skillful one, but either because of his blind reliance on the virtues of internal fixation and perfect reapproximation of fragments, or lack of objectivity, he has condemned a young man to a disability greater than the one that the paraplegia had already imposed on him.2. It does not suffice to adhere to the aphorism expressed by Simon Bolivar, the Latin American liberator, “Good judgment comes from experience and experience comes from bad judgment”, at least not when we are dealing with the health and future of other human beings.

The rampant lack of objectivity, clearly demonstrated in this instance, can be improved if we, the educators, emphasize objective reasoning to our students. Unharnessed enthusiasm and fascination with surgical experiences must be tempered with reason. “La raison avant la passion”.

REFERENCES:

1.   Sarmiento A. The future of our specialty. Acta Orthopedica Scandinavica. 71 (6): 574-579, 2000

2.   Sarmiento A. Have we lost Objectivity?  Jour. Bone and Joint Surgery. Vol. 84A:  1254-58, 2002.

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.

Reflections on Fracture Healing and Care

by Augusto Sarmiento, MD

Fifty-five years after completion of my residency I have finally stopped working at the University and Hospital. It was a painful decision, precipitated by the deteriorating health of my wife.  We ended up leaving Miami and moving to Punta Gorda, a small community in Southwest Florida. Only four months have passed since my new life began, so I hope additional time will assuage the profound unhappiness I now experience from not being able to teach orthopaedic residents.

Trying to identify topics that I could dwell on with some confidence and share with my colleagues, I quickly ran into fracture healing and care, because since the early 1960’s I worked on these subjects with great enthusiasm and perseverance. I first published my initial work on what I considered the positive role that motion plays in fracture healing. The concept was severely criticized in orthopaedic/scientific circles as being anathema to well-established principles.  At that time, the AO, a powerful scientific/commercial organization, was making rapid advances in marketing the use of surgical appliances aimed at obtaining rigid immobilization of fracture fragments, which they considered to provide the best and most expeditious environment for healing.

More than one hundred publications from our laboratories and clinics at the Universities of Miami and Southern California have solidified my firm belief that diaphyseal fractures rather consistently heal, not because they are rigidly immobilized  but despite the immobilization. Rigid immobilization deprives the injured bone from the stresses that every tissue in the body must be subjected in order to maintain desirable biological and mechanical properties.

Following the initial injury there is bleeding at the fracture site, a phenomenon that has led some to mistakenly believe that the hematoma plays a role in osteogenesis. However, there is nothing to support such a mythological idea. Quite the contrary, it is likely that the hematoma is an obstacle to healing and must be gradually absorbed. If that were not the case, we should be injecting blood into fractures in order to enhance healing.

When a fracture is not rigidly immobilized and the injured limb is subjected to the gradual stresses that come from the gradual introduction of muscle activity, as well as motion of the extremity, a massive capillary invasion at the level of the fracture takes place. (Figs.   1.a. & b.).

Fig. 1.a.  Massive capillary Invasion

Fig. 1.a. Massive capillary invasion when the fracture is not rigidly immobilized.

Fig. 1b) When the fracture is rigidly immobilized the capillary invasion does not take place. The medullary circulation is rapidly  restored.

Fig. 1.b.) When the fracture is rigidly immobilized the capillary invasion does not take place. The medullary circulation is rapidly restored.

 This vascular phenomenon is the single most important one in the process of fracture repair because the perithelial and endothelial cells of the capillaries undergo osteoblastic metaplasia and form peripheral callus.(Figs. 2.a. & 2.b.).

Fig. 2.a.

Fig. 2.a.

Fig. 2.b.

Fig. 2.b.

In the rigidly immobilized fracture the healing occurs from growth of osteons but without peripheral callus.  Mechanically, the strength of a callus is measured by the diameter of the callus.

The next related important observation is the fact that in fractures of both bones in the lower leg and forearm the initial shortening experienced does not increase with the gradual introduction of weight bearing activities. The interosseous membrane, an elastic structure, prevents the increase in shortening while still permitting elastic pistoning. (Fig. 3a and 3b). Needless to say, fractures with extensive damage to the membrane experience greater shortening and lack the benefits of acceptable of the initial shortening or the maintenance of manually corrected length.

Fig. 3.a.

Fig. 3.a.

Fig. 3.b.

Fig. 3.b.

I am not aware of any work that has negated the validity of the observations I have just made. Furthermore, I am keenly aware of the many advantages that surgical stabilization possesses, which explains the fact that despite its biological negative features, it is taught to current generations of orthopaedists as the only sound approach to fracture management. A logical balance between the two opposing schools is necessary since there is a place for both of them. Economic considerations should not be ignored.

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.

How Urgent are Open Fractures?

Dahners photo

Dr. Laurence Dahners

by Laurence E. Dahners, M.D.

A relatively new factor to consider in the treatment of trauma victims with open fractures is the fact that the data do not support the concept that open fractures are “emergencies requiring surgical debridement within six hours.” Initial studies were in pediatric open fracture but recently papers regarding infection rates in adults have been published as well. None of these studies has shown a statistically significant difference in infection rates in fractures debrided in less than six hours as compared to those debrided between six and twenty-four hours. The “trends” (non statistical differences) lean toward higher infection rates in those debrided in the first six hours! It does make a huge difference how soon the antibiotics are started so this remains very important. It is difficult to rationalize why early debridement would not lower infection rates but I hypothesize that it may be easier to differentiate necrotic from viable tissue when the debridement is carried out after six hours. In any case I now perform debridement during the daylight hours.

Dr. Dahners is a Professor of Orthopaedic Surgery at the UNC School of Medicine in Chapel Hill, NC, USA.  His clinical focus is on trauma and his research interests are in ligament physiology, ligament healing, ligament growth and contracture, and bone healing and the biomechanics of internal fixation.  You can see his “Pearls of Orthopaedics” on OrthopaedicList.com.