Doctor Tarlow on Knees - The Lighter Side

Uncertainty Surrounding Medicare Payments to Physicians Continue

2010-02-28T14:09:00.005-07:00

Most physicians want to be and enjoy being providers of care to our Medicare aged citizens. However, the business person inside these health care providers realize that at the end of the day this work effort must be compensated by reasonable payment. Physician reimbursement for services has been substantially reduced over the last 20 years.

By example, Medicare reimbursement to an Orthopedic Surgeon for Total Knee Replacement surgery has fallen from $1816 in 1992 to $1412 in 2009, a 22 % drop. When adjusted for inflation this is nearly a 50 % drop in payment for services. Beginning tomorrow we all fall over the cliff, with a further 21 % cut down to an estimated $1116. Leaders of organized medicine call this reduction "the cliff" because, in their view, many physicians will not be able to afford to see new Medicare patients, or even stay in the federal program, or even stay in practice if their Medicare pay drops by more than one fifth. They also call it a cliff for seniors who may not be able to find a physician willing to treat them.

This uncertainty in Medicare Physician payments is not new. Proposed cuts have been staved off by temporary congressional measures for many years. The SGR formula behind Medicare payments is not sustainable or practical, yet a permanent fix can not be agreed upon. Many in the health care world believe the SGR is a discredited and dysfunctional tool.

Personally, the uncertainty over the last 8 years associated with being a participating Medicare provider is increasingly becoming intolerable. While the news today is that a 21 % cut in Medicare reimbursement is taking affect on March 1, the news tomorrow may be that Congress has replaced the SGR and has reversed the cuts in physician Medicare reimbursement. Being on a reimbursement roller coaster that is politically controlled is not be the best business model for U.S. Physicians. I am not going to immediately withdraw from Medicare by the March 17 deadline (involved process requiring legal advice and review all insurance contracts since some require Medicare participation). However, if this matter can not be resolved by the 2011 deadline of December 31, 2010, I will most likely have no choice but to become a Private Medicare Contractor and bill patients directly for my services with a market driven fee schedule. The "cliff" analogy appropriately describes the current state of affairs in Medicare Physician reimbursement.

Below are some excerpts and links.

From the NPR website February 26, 2010- Medicare payments to doctors will fall by 21 percent starting on Monday, but Congress may soon act to block the cut. It's the latest reminder of a chronic problem for the federal government: figuring out how to pay doctors who treat Medicare patients.

The story goes all the way back to 1965, when the federal government was about to launch Medicare — the health-insurance plan for the elderly.

From Medscape Today February 26, 2010- If physicians are true to their warnings, Medicare patients next week may experience difficulty making an appointment. A recent poll conducted by several medical societies representing neurosurgeons, for example, revealed that almost 40% would cut back on seeing new Medicare patients if reimbursement continues to decline, while 18% would stop accepting new Medicare patients altogether. Another 27% said they would treat fewer established Medicare patients.

From AAOS bulletin February 26, 2010 - Although Congressional leaders have said that they will enact legislation to stop the scheduled cut and also potentially eliminate the Sustainable Growth Rate (SGR) formula, such action is not guaranteed to occur before March 1. Additionally, differences between the House and Senate health system reform bills mean that the impact of further legislation on individual physicians is not yet clear.

Specialized Orthopaedic Hospitals Have Better Outcomes for Hip and Knee Replacement

2010-02-20T17:05:00.005-07:00

A study carried out by researcher's at Iowa's Carver Medical College concluded the more specialized a hospital is in orthopedic surgical care, the better the outcomes appear to be for patients undergoing hip and knee replacement surgery.

Among more specialized hospitals, there were fewer serious post-surgical complications such as blood clots, infections and heart problems, as well as fewer deaths.

The findings, which were published online Feb. 11 by the British Medical Journal, were based on data for nearly 1.3 million patients who received hip or knee replacement surgeries between 2001 and 2005 at 3,818 hospitals in the United States.

"The findings suggest that more specialized hospitals have better outcomes even after we account for the type of patients each hospital cares for and the number of hip and knee replacement surgeries that each hospital performs," said the study's lead author Tyson Hagen, M.D., fellow in rheumatology at the UI Roy J. and Lucille A. Carver College of Medicine and UI Hospitals and Clinics.

"While specialization appears to be an important indicator of quality, it is just one factor that patients might want to consider along with other important factors, such as how close the hospital is to home," Hagen added.

Dr. Tarlow comments : These researchers developed a method to a measure of a hospital’s orthopaedicspecialization - Hospital specialization differs from hospital volume and canbe defined as the proportion of a specific hospital’sadmissions falling into a single disease category - and then stratified the patients based on certain characteristic such as age and overall health. The conclusion of this study confirms what one would assume using common sense; People should expect to receive better care and have better outcomes at a facility that has a great familiarity with a specific form of treatment. There is a movement in the U.S. to limit future planning and construction of these specialty hospitals be it orthopedic, neurologic, cardiac or what have you. These studies are likely being carried out to support the current trend of smaller, specialty hospitals, many of which are physician owned. There is no questions that patients receive great care and continually comment that these specialty facilities exceed their expectations. I see this first hand at Arizona Orthopedic Surgical Hospital.

Should Surgeons Meet Patients Online ?

2010-01-23T12:00:00.004-07:00

A New York Times article January 20, 2010 explored the idea of patients initially contacting health care providers online for treatment options and price quotes for treatment. The article focuses on patients with plastic surgery care, a service usually not covered by health insurance and thus paid for on a cash basis.
Here is an excerpt from the article; "You log on to SurgeonHouseCall.com and create a free patient profile declaring your wish to get a tummy tuck. You fill out a brief medical history and include photographs of the problem area.

In no time, three plastic surgeons offer detailed opinions on the best course of action — with price quotes. It’s as if SurgeonHouseCall.com co-opted the LendingTree slogan, “When banks compete, you win."

While I see this model relevant today I see this more likely to become a reality in the future when physicians are competing on price rather than the health insurance plan fixed fee market currently in place. Doctors will compete on price when they opt to drop off insurance plans such as Medicare or Pacificare (just random examples) or when treating people using Health Savings Accounts to pay for their care. In each of these scenarios one would expect treatment plan, the number of tests ordered, and price to matter when choosing a health care provider. This method would allows the patient to "shop" for physician services similar to shopping for a television or appliance because the patient will factor in price just as they do with other purchasing decisions.

Advocates of virtual consultations suggest that convenience and receiving multiple opinions online benefits to a prospective patient. “It changes the first in-person consultation, empowering the patient with knowledge of the procedure, decreased anxiety level and financial readiness”. Patients benefit from a online type of evaluation. They get an idea of the cost, and what you get for that cost before they make a commitment, before they walk through that door to see the physician. It is a way for patients to use the online information exchange with a surgeon for a connection to the physician, his online mannerisms, his thought process and treatment option. This may be one way for patients to choose their care provider in the not to distant future.

Before online patient information exchange becomes main stream important legal issues must be addressed.

Providing a diagnosis to patients across state lines also raises legal issues. The online contact can not be a medical consultation. A patient-doctor relationship is “clearly established and begun when a physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees.” Such a distinction matters, because usually doctors should only be able to care for patients in states where they are licensed. Under any conditions it would be poor practice and foolish to diagnose a patient and outline a treatment plan without seeing the patient face to face.

Paramount in this brave new world is ensuring that patients receive the same standard of care online and in person, said Dr. Chaudhry of the medical board association. “It should be the same exact standard as if the patient was in your examining room. You can’t cut corners.”

I see in the not so distant future a prospective Orthopedic Surgery patient making online contact with several physicians, providing the online doctor with certain generalized facts about their condition (with or without photographs and xray/mri images), and receiving in return several hypothetical diagnoses and cost estimates to treat these conditions. The patient will then review the options and then decide if and when to seek treatment. In this new Online Information Exchange world this patient is empowered with the background knowledge gained from their online communication - this patient will have a more meaningful dialogue with their doctor leading to a better decision for the treatment they may receive.

Fibromyalgia Syndrome: Outcome Following Total Knee Replacement Not As Good As Most Other Patient Groups

2010-01-17T12:11:00.005-07:00

According to Wikipedia, fibromyalgia is characterized by chronic widespread pain and allodynia, a heightened and painful response to pressure.[1] Fibromyalgia symptoms are not restricted to pain, leading to the use of the alternative term fibromyalgia syndrome for the condition. Other core symptoms include debilitating fatigue, sleep disturbance, and joint stiffness.

A Mayo Clinic study of 141 Total Knee Replacements done in patients with Fibromyalgia Syndrome concluded that nearly half of the patients reported continued knee pain after replacement surgery (much higher than most other patient groups) and more patients in the study had trouble regaining knee motion. Total Knee Replacement surgery did provide improvements in pain compared to preop levels.

The conclusion is that there is a high prevalance of continued pain and stiffness in Fibromyalgia patients undergoing Total Knee Replacement surgery. The Orthopedic Surgeon should counsel these patients pre-operatively so this sub group of people can make an informed choice as to whether to have this surgery and to align expectations with reality.

Youth Sports Injury; Common Sense Needs to Prevail

2009-11-29T19:41:00.005-07:00

Children playing sports such as soccer, football, basketball, baseball, running, dancing and gymnastics are suffering musculoskeletal injuries at unprecedented rates.

Some alarming statistics from Safe Kids, USA: 3.5 million children age 14 and younger are treated for sports injuries each year, nearly half of all injuries to middle school and high school athletes are overuse injuries, and almost 40% of sports related injuries treated at hopsital ER departments are aged 5 to 14 years old.

Youth sports have become big business. Training intensity is high for individual and team sports, with many athletes training 10-20 hours per week. Many adolescent athletes concentrate on one sport and do not cross train or change body loading environments. There has been an increase in youth injuries that require surgery. Overuse injuries such as stress fractures and little league shoulder and osteochondritis dissecans can cause growth disturbances or permanent joint injury. ACL surgeries, elbow surgery and shoulder surgery are far too common place. Many of these injuries can be prevented by allowing minor injuries time to heal (keep youths out of practice and competition for as long as it takes for their bodies to heal), limit participation in any one sport to 8 months or less. If common sense does not prevail our youth athletes will continue to suffer injuries that may have detrimental long term consequences to their health. This post was inspired by an article in AAOS Now entitled The Changing Landscape of Youth Sports Injuries.

Platelet Rich Plasma (PRP) Shows Promise in Helping Body Heal Injuries

2009-11-29T19:14:00.006-07:00

Connective tissue engineering is a rapidly evolving field in medicine and orthopedic surgery. The ideal biologic tool would be safe, simple to use, inexpensive, and available immediately at the point of care. Importantly, it would also have to be effective. Platelet-rich plasma, meets many of these criteria. Platelet Rich Plasma tissue grafting is a simple, safe and quick method of utilizing healing factors contained in a small blood cells(Platelets). Two vials of a patients venous blood is spun at high speed in a centrifuge, separating the platelets containing growth factors from red blood cells. The tissue graft is available in liquid form or in a putty form (if activated with calcium chloride or thrombin). The liquid can be injected into injured tendons (office procedure) in diseases such as tennis elbow, jumper's knee, or Achilles tendinitis. The putty form is used during surgical procedures such as ACL reconstruction or rotator cuff repair. Some proponents believe that PRP may catalyze the body's repair mechanism, improve healing and shorten recovery. Some studies indicate PRP may be beneficial in the healing process. Several good scientific studies are underway to help us further understand the true benefit of PRP.

Will a Shortage of Nuclear Isotopes Mean Less Effective Medical Tests?

2009-11-16T01:04:00.004-07:00

This from a recent "Popular Science" article: Nuclear imaging is used on tens of thousands of patients every day to take pictures of their hearts, lungs, kidneys, bones, brains and other organs. Doctors inject isotopes into a patient and use a radiation-sensitive camera to locate blood clots and tumors or to diagnose seizures, among other things. Mo-99 is critical for about 80 percent of all nuclear-medicine tests because as it decays, it releases a daughter isotope called technetium-99m, which is energetic enough for the camera to see, but its short, six-hour half-life means it conveniently decays to practically nothing after 24 hours. Unfortunately, Mo-99 can’t be stockpiled for more than a few days.

Just five reactors supply 95 percent of the world’s Mo-99, and they’re all past their prime. A nuclear reactor’s average life span is 40 to 50 years. Chalk River is 52 years old. The Dutch reactor—which came back online in August—is 47. The other three, in France, South Africa and Belgium, are 42, 43 and 47, respectively. The Canadian Chalk River reactor and the Dutch reactor are both down at this time.

In my practice as a Knee Surgeon I use nuclear medicine testing (Tech 99 bone scan) to assess patients for partial knee replacement surgery (along with xray, physical exam findings and medical history taking). Other orthopedic surgery use includes diagnosing stress fracture (MRI can also do this) and assess for the spread of tumor or infection in the bone.

Cost of Total Knee Replacement

2009-11-07T11:15:00.003-07:00

The CPT billing code for TKR is 27447, for unicompartmental knee replacement 27446 and for patellofemoral arthroplasty 27438. These codes are useful to patients when discussing cost with insurance companies or surgeons. Surgeon fee varies between physicians but is typically several thousand dollars (Dr. Tarlow fees available on request). Surgeon payment varies between insurers and these payments are typically 25-50 % of stated surgeon fees. Medicare surgeon payment in Arizona in 2009 is $1411. Similarly, hospital payments are typically 25-50 % of hospital charges. Do not be aghast when receiving the statement for your surgeon, assistant surgeon, anesthesiologist or hospital/surgery center. Once the fees are adjusted by the payer the cost will be reasonable and affordable for most budgets. Charges typically associated with TKR include surgeon fee for total knee (27447), surgeon fee for Computer Navigation (20985), surgical assistant fee (12-20 % of surgeon payment — not fee), anesthesiologist fee, hospital fee and physical therapy fee. If you would like to know more or have specific questions about medical costs, contact me via my website.

Young, Growing Athletes Should Not Put Off ACL Surgery

2009-11-01T20:41:00.005-07:00

In some cases skeletally immature patients with anterior cruciate ligament knee injuries are advised to delay surgical treatment of the injury and wear a brace for activities until their bones have completed growth. The reason for this is the hypothetical risk of inducing a growth disturbance to the bones around the knee. This must be balanced against the more likely risk of further permanent knee damage by delaying surgical stabilization of the knee. ACL surgery can be done and should be done in young patients with open growth plates (skeletally immature-bones are still growing) to mitigate the risk of permanent damage to the knee. The surgical technique must be modified. The modifications include using a soft tissue graft and using graft fixation devices that do not cross the growth plate. Grafts must be placed anatomically. A study of 70 patients 14 years of age or younger by Theodore Ganley, M.D., J. Todd Lawrence, M.D., PhD and Nina Agrawal, BA concluded that delaying surgical treatment of these patients longer than 12 weeks resulted in a 4 fold increase of irreparable medial meniscus (loss of the medial meniscus greatly increases the chance of knee arthritis), an 11 fold increase of chondral (joint surface) injury in the lateral compartment, and a 3 fold increase in patellotrochlear chondral injury compared to the young athletes that had earlier knee ACL reconstruction. The noted damages in the non operative group occurred despite activity modification, bracing and continued knee rehabilitation. Their results highlight and quantify the risk of delaying ACL surgery in young athletes and emphasize the continued effort on injury prevention for young athletes.

Ban on Percocet and Vicodin Being Considered Due to Tylenol Toxicity

2009-09-21T23:38:00.005-06:00

Two of the most common surgical pain relievers may be banned by the FDA in the near future. This is not based on the addictive potential of the narcotic but because of the dangers posed byAcetominophen, or APAP, commonly known as Tylenol. Percocet in the most common form contains 5 mg of oxycodone and 325 mg of Acetominophen. Vicodin contains 5 mg of hydrocodone and 500 mg of Acetominophen. The concern is that more than 4000 mg of Acetominophen daily can cause liver damage or death. So many common medications available over the counter contain Acetominophen that a person taking Percocet or Vicodin for post op pain may unknowingly exceed the daily Acetominophen limit by also taking a cold or flu or allergy relief medicine at the same time. Acetominophen is an active ingredient found in over 600 over the counter and prescription medications.
A federal advisory panel on June 30, 2009, voted 20-17 in favor of implementing the ban. The matter now goes to the U.S. Food and Drug Administration for final action. Visit www.fda.gov/cder to learn more.

Weak Hip Stabilizing Muscles Linked to Knee/Leg Injuries in Runners

2009-06-28T19:28:00.006-06:00

80 % of running injuries occur at or below the knee, suggesting that there is some common mechanism of injury as the root cause of these injuries, according to a study, Suspected Mechanisms In the Cause of Overuse Running Injuries, published in Sports Health (May/June 2009). According to the authors, most running injury risk factors can be categorized as either 1) atypical foot pronation mechanics or 2) inadequate hip muscle stabilization. However, no link was found between atypical foot mechanics and running injury mechanisms. In contrast, a large and growing body of literature suggests that weakness of hip-stabilizing muscles leads to atypical lower extremity mechanics and increased forces within the lower extremity while running. Runners can help prevent these injuries by including "Core" and Hip strengthening exercises to their fitness program.

Blog change of address: blog.tarlowknee.com

2009-06-23T13:42:00.005-06:00

Some of you may have noticed that the blog has a new address. It is now under the same domain as my medical practice, which is at http://www.tarlowknee.com/. The change is mainly for aesthetic reasons, and won't affect anything about how the blog is run.

The new address is:
http://blog.tarlowknee.com/

The change shouldn't affect you. Any old links at http://tarlowmd.blogspot.com/ will automatically redirect to the new location, so if you like, you don't even need to update your bookmarks.

Please leave a comment if anything stops working as expected due to this change, though.

What is an Orthopedic Surgeon ?

2009-06-07T12:53:00.006-06:00

Orthopedic surgery or orthopedics (also spelled orthopaedics) is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and non-surgical means to treat musculoskeletal trauma, sports injuries, degenerative diseases, infections, tumors, and congenital conditions. Complete the fourteen years of formal education and training after high school and you too will a Board Certified Orthopedic Surgeon. Orthopedic Surgeons that have completed a Fellowship can choose to focus their practice within a certain sub specialty area.

4 years of College - any degree acceptable
4 year accredited Medical School (Doctor of Medicine/Doctor of Osteopathic Medicine include certification by USMLE testing)
1 year of Internship (usually 12 one month rotations in variety of medical fields)
4 years of Orthopedic Surgery Residency (Adult, Pediatric, Orthopedic Trauma,Tumors, Basic Science and Anatomy including American Board of Orthopedic Surgery written and Oral testing)
Optional : 1 year sub speciality Fellowship (Sports Medicine, Adult Reconstruction, Hand, Shoulder and Elbow, Foot and Ankle, Spine, Trauma, Tumors, Pediatric, Research).

Dr. Tarlow did two fellowships, one in knee surgery in Sweden-1987, and the other in Sports Medicine with Dr. James R. Andrews, M.D. in Birmingham, AL-1988. He practice specializes in the treatment of the Knee.

Public Forum Needed to Discuss Health Care Costs/Quality

2009-06-07T12:31:00.006-06:00

Two recent articles attempted to discuss the topic of health care costs in America. One article appeared in The Oregonian, Onetime insiders help with health bills, and one article appeared in the The Arizona Republic, Globe-trotting to cut medical costs. My opinion is that neither of these articles were based on accurate facts and neither addressed the intended topic. I sent an e-mail to each of the authors stating "I am hopeful that you will try again to address this issue and use better journalism skills to write something meaningful and timely regarding health care costs".

The time has come for Americans to become knowledgeable about medical charges and medical payments and the role of the health care providers, hospitals, health insurance industry , pharmaceutical companies, and trial lawyers (liability and malpractice costs) have on the cost of health care in the United States. As a physician I understand I need to discuss health care costs with patients and I better be able to compete on quality and price in the future. Empowered with the true facts we can improve the delivery and economy of medical care in our country.

Living with a Knee Replacement: Which Activities Are Okay ?

2009-05-30T14:24:00.008-06:00

Innovations in Total Knee Replacement offer the potential for high demand function with lower failure rates over the 20-30 year life of the components. These advanced engineered components are new to the market and the potential benefits have yet to be proven.

Even so, a 2007 survey of joint replacement surgeons show a trend to allow more activities in patients with artificial joints. 95 % of joint replacement surgeons place no limitations on swimming, golf, walking and biking on level surfaces and stair climbing. Patients are still discouraged from jogging and difficult skiing. About half of the Knee Surgeons allow doubles and singles tennis.

Patients who chose to play sports after joint replacement should train for their sport, build up back, hip and knee strength, and be aware of the potential risks (early failure of replaced joint or fracture of leg bones) of athletic activity after joint replacement.

Primer on Knee Arthroscopy

2009-05-16T13:03:00.014-06:00

The most common surgical procedure in Orthopedic Surgery is arthroscopy of the knee. The operation is performed at a hospital or outpatient surgical center. The patient is usually administered a general anesthetic. The procedure usually takes 30-45 minutes.Patients are on crutches for a day or day, take oral pain medications for less than a week, return to desk work in 2-4 days, and are usually fully recovered in 2-4 weeks (for simple arthroscopic procedures such as menisectomy, chondroplasty, loose body removal and lateral release).

Arthroscopy outcomes vary, but can be predicted based on age and diagnosis. As a rule, if the patient is younger than 55 with only one problem (only a torn meniscus, only a loose body, only a small area of joint surface damage) tend to have a higher rate of successful surgical outcomes. Patients over 55 with more than one disease process (most common is torn meniscus with chondral damage – also know as arthritis) have unpredictable outcomes after knee arthroscopy [improved knee outcome in 60% range for these multiple disease process knees].

The best surgical outcomes are after Arthroscopic Medial Menisectomy, Arthroscopic Lateral Meniscal repair and Arthroscopic Loose Body removal. The least predictable surgical outcomes are with Arthroscopic Chondroplasty for arthritis and Arthroscopic Lateral Retinacular Release for patellar tracking problems.

A more detailed report is found on the Knee Arthroscopy page on the web site of Doctor Tarlow.

Bicycling and Knee Pain

2009-05-09T14:15:00.007-06:00

Knee pain is a common cycling ailment. The two most common causes for knee pain in cyclists is iliotibial band (IT band) syndrome and patellofemoral syndrome. Both are overuse conditions.

Cyclists may be able to avoid these conditions by pedaling with low resistance and keeping a cadence up to at least 80-90 rpm, and minimizing hard/hill riding. Add a stretching program for legs and be sure to do core training exercises.

Be sure your bike is adjusted properly including the saddle height and position. Have an expert advise you on crank length- being too long can predispose to knee pain. Avoid pushing in high gears. Finally, be sure you have correct cleat alignment/motion.

Tom Bratcher, Physical Therapist at Center for Athletic Performance in North Scottsdale , is an expert in helping cyclist attain proper mechanics with correct bike adjustments and outlining a treatment program to improve body function, relieve pain and improve performance.

Total Knee Replacements Highly Successful in First 3 Years

2009-05-09T13:37:00.006-06:00

A British Study looked in the National Registry to determine revision surgery rates of 80,697 primary Total Knee Replacements between 2003 and 2006. This was an observational study and a revision for any reason (infection, loosening, instability, fracture) was the defined end point of the study. Observational studies have many limitations, but the numbers in this study still have some validity and some interest.

The overall primary knee replacement revision rate was 1.4% for cemented total prosthesis, 1.5 % for cement less total prosthesis, and 2.8% for uni compartmental prosthesis at three years. Patients younger than 55 years at the time of the primary TKR had the highest revision rate and those older than 75 years at the time of primary TKR had the lowest rates. Overall, this reports shows that revision rates in the first 3 years after knee replacements carried out in the NHS in England since April 2003 were low.

News Flash from Advanced Knee Care, P.C.

2009-04-29T19:15:00.004-06:00

The website of Doctor Stefan Tarlow, M.D., Advanced Knee Care, P.C., was upgraded last week. There is newly composed content discussing Minimally Invasive Computer Navigated Total Knee Replacement, Anterior Cruciate Ligament Reconstruction, and Cartilage Restoration Surgery.

There are new topics addressed including Online Electronic Personal Health Records and Quality Measures in Health Care.

The forms and post op instructions have been revised. A complete list of Dr. Tarlow's participating health plans has been added.

Finally, I now offer "Request an Appointment Online".

Dr. T.

Electronic Medical Records a Good Thing for Everyone

2009-04-12T12:52:00.018-06:00

This announcement was made Thursday, April 9, 2009: The federal government is establishing a virtual (electronic) lifetime health record for all servicemen and women during and after their military careers, President Obama announced Thursday.

Electronic medical records will provide "a framework to ensure that all health care providers have all the information they need to deliver high-quality health care while reducing medical errors," the White House said in a background statement.

This technology is available to everyone. I am a strong proponent of electronic medical records. I have made this a top priority in my medical practice. With the initiative started at Advanced Knee Care last month, we now provide our patients with copies of their records and encourage them to store their health information at a secure, web based location for easy accessibility. Having access to your own health information will improve the quality of care you receive and reduce medical errors. Knowing the facts about your own health help you and your physician to make better health care decisions. Link for electronic health records specifics on my web site.

Cartilage Restoration Surgery of the Knee - Carticel procdure by Genzyme

2009-03-29T11:07:00.006-06:00

The ideal treatment for any knee injury or disease is a biologic treatment that can restore the knee to a near normal state. Anterior Cruciate Ligament reconstruction, meniscal repair, and anatomic repair of fractures of the knee are three examples of successful biological surgical repairs for the injured knee.

Symptomatic full thickness chondral lesions of the knee pose a difficult management issue for both orthopedists and patients. If injury leads to articular cartilage cell death the best treatment is restoration of the joint surface cells (articular cartilage-the shiny white surface that forms all joints in the body). One procedure to restore the knee surface to near normal is termed ACI or autologous chondrocyte implantation ( the other treatment option not discussed in this post is OATS - OsteoArticular Transfer System for smaller lesions - http://aboutjoints.com/patientinfo/topics/oats/oatspg3.htm or Osteochondral Allograft Procedure for larger lesions- http://www.proceduresconsult.com/medical-procedures/osteochondral-allograft-OR-procedure.aspx#preprocedure) . Cartilage restoration is a procedure has strict use criteria, or indications. The surgical indication for ACI is a symptomatic, full thickness, weightbearing chondral injury of the femoral articular surface in a physiologically young patient who can be compliant with the 18 month long rehabilitation process. The results of ACI surgery for lesions on the tibia and patella are not as consistently successful and use for this part of the knee is not usually paid for by insurance companies. Also, ACI is not a treatment for Osteoarthritis (two reciprocal joint surfaces are damaged with xray changes of joint space narrowing, and bone spur formation). 3T MRI can be helpful with assessing knees for ACI but in almost all circumstance a knee arthroscopy is performed to be sure the knee is suitable for ACI. At the time of Diagnostic Knee Arthroscopy the articular cartilage cells are harvested for reimplantation at a later date (after cell expansion in the lab at Genzyme Biosurgery).

For those readers who want to know more regarding surgery technique and rehabilitation protocols see this link: http://www.carticel.com/patients/treatment.aspx

Carticel is a industry trade name. The following is an excerpt from the Genzyme Biosurgical web site.

" CARTICEL is a biologic product used to repair articular cartilage injuries in adults who have not responded to an arthroscopic or other surgical repair procedure. It uses your body’s own cultured cells to regenerate the articular cartilage in your knee during a surgical procedure called autologous chondrocyte implantation (ACI). CARTICEL is the name of the cells that are grown from the samples (or biopsy) taken from your knee. When implanted into a cartilage injury, these cells can form new hyaline-like cartilage. CARTICEL poses little risk of disease transmission since it comes from your own tissue, and is not transplanted from an unrelated donor. CARTICEL is not indicated for the treatment of cartilage damage associated with generalized osteoarthritis."

Visionaire Patient Matched Instrumentation (PMI) for Total Knee Replacement

2009-03-29T10:55:00.004-06:00

Below is the news release from Smith & Nephew Orthopedics announcing the launch of VISIONAIRE Patient Matched technology for total knee replacement. I have had the opportunity of being one of the surgeons chosen to use this technology at the time of the FDA approval but prior to general release. Since November, 2008 I have implanted eleven Journey Oxinium Total Knees using Visionaire Patient Matched Instrumentation (PMI) custom instrumentation. In my opinion it is an excellent system to assist with precision placement of a total knee. This technology uses anatomic data specific to each individual patient which allows the surgeon to more precisely align the knee components compared to Traditional Total Knee Replacement. PMI does reduce operating room time, anesthesia time, and has a lower fracture risk compared to computer navigated Total Knee Replacement. Visionaire Patient Matched Instrumentation (PMI) is compatible with Minimally Invasive Surgery (MIS). Surgeon skill is still required to properly balance the capsule/ligament structures leading to a stable, properly functioning knee. Top Photo: Cartoon of PMI Custom Block attached to Tibia - note cutting slot for precise proximal tibial resection. Lower Photo: Cartoon of PMI Custom Block attached to femur- note cutting slot for precise distal femoral cut. Note two holes on front face of block which properly rotates femoral component. . One day Smith and Nephew will have more information regarding this treatment option on their web site and I will link to this information as it becomes available.

Memphis, TN, February 23, 2009 – Smith & Nephew, Inc. (NYSE: SNN, LSE: SN) Orthopaedic Reconstruction & Trauma today announced the introduction of VISIONAIRE^{^◊} Patient Matched instrumentation for use in total knee replacement surgery. The VISIONAIRE system is proprietary technology that uses a patient’s MRI and x-rays to create custom surgical instrumentation for use with the Smith & Nephew portfolio of high performance knee implants.

By using instruments designed from each patient’s anatomical data, surgeons can accommodate the unique shapes and angles of the joint while precisely aligning the implant. The disposable, patient-specific instruments help surgeons eliminate multiple steps and valuable minutes from knee replacement surgery, thus decreasing the risk of infection as well as the amount of time a patient is under anesthesia.

Additionally, the VISIONAIRE system helps hospitals reduce expenses as it eliminates the sterilization costs associated with the traditional, reusable instruments it replaces.

“VISIONAIRE instrumentation is a mutually beneficial technology for patients, surgeons, hospitals and Smith & Nephew,” said Joseph DeVivo, president of Smith & Nephew Orthopaedic Reconstruction & Trauma. “The VISIONAIRE system is a core component of our strategy. Patient matched technology is the future of orthopedics and the future of Smith & Nephew, and this launch represents the start of our efforts.”

VISIONAIRE technology received 510(k) clearance from the Food and Drug Administration (FDA) in November 2008 and will be launched in targeted US markets throughout 2009. The company is working to expand its use of this proprietary technology across its portfolio of high performance implants for knee and hip replacement and resurfacing.

Smith & Nephew is the first and only major medical device company to design, build and distribute this powerful new technology for patients suffering from advanced osteoarthritis of the knee. Other implant makers rely on systems designed and built by third parties.

MRI Scanners: 3T Machines Are Best - Patient Care and Quality

2009-03-07T08:44:00.007-07:00

Patient Care Issue:

Tesla (T) is the unit of measurement quantifying the strength of a magnetic field. Prior to the 3 Tesla Machine, the high-field standard was 1.5 Tesla. The 3T scanner generates a magnetic field that is twice the strength of 1.5 Tesla machines and 10 to 15 times the strength of low field or open MRI scanners. The magnetic field produced by a 3T MRI System yields exceptional anatomic detail. The scan time for a 3T machine is less than 20 minutes (low field scanner time is 60 minutes). Thus, if a picture is worth a thousand words, the 3 Tesla MRI is an encyclopedia. The increased image clarity revealed by 3T is particularly beneficial for pathological conditions involving the brain, spine, and musculoskeletal system.

I typically refer my patients to Simon Med Radiology ( simonmed.com), specifically one of their four locations which have a 3T scanner. These locations are Scottsdale, Mesa, Phoenix and West Valley. It is important for me to use the best available technology to treat my patients. The detailed images from a 3T knee MRI improves my diagnostic accuracy. This is one way in which I can provide patients better care.

Health Care Cost and Quality Issue:

Ten years ago, the age of a scanner might not have mattered so much. Now, said Dr. Gary Glazer, the chairman of radiology at Stanford, technology has advanced so much that the older scanner “is not the same machine.”

More than 95 million high-tech scans are done each year, and medical imaging, including CT, M.R.I. and PET scans, has ballooned into a $100-billion-a-year industry in the United States, with Medicare paying for $14 billion of that. But recent studies show that as many as 20 percent to 50 percent of the procedures should never have been done because their results did not help diagnose ailments or treat patients.

“The system is just totally, totally broken,” said Dr. Vijay Rao, the chairwoman of the radiology department at Thomas Jefferson University Hospital, in Philadelphia.

Radiologists say a decent M.R.I. scan can clearly shown what might be wrong in a patients knee. But non diagnostic scans from old technology machines, medical experts say, are part of a growing problem with medical imaging.

Many factors contribute. Insurers pay the same for a scan done on a 10-year-old machine as one on the latest model, though the differences in the images can be significant.

Insurers do not distinguish between scans that are done poorly or done well or read by less- or more-qualified doctors. Aside from mammography, whose standards were established by a law that went into effect more than a decade ago, the field is largely unregulated.

The Health Care Cost and Quality paragraph points out another way in which the delivery of medicine can be improved and this improvement can be combined with cost containment.

Posterolateral Corner Knee Injuries: An Uncommon but Disabling Injury

2009-02-21T09:23:00.005-07:00

Most often I post on common knee issues using terms the non medical person can easily follow. However, today's post will deviate from using easily understood terms as I explain an uncommon but debilitating knee injury. This post will contain a lot of medical jargon

Modifying to some degree an excerpt from Orthopedics Knowledge On line by William Grana, M.D. "Posterolateral corner injuries are defined to be an injury of the structures on the posterolateral (and to a variable degree lateral) aspect of the knee which contribute to an increased amount of abnormal external rotation of the tibia on the femur making the patient feel their knee is unstable. Most posterolateral corner knee instabilities are the result of injuries such as blows to the anteromedial aspect of the knee, contact and noncontact hyperextension injuries, and varus contact injuries to a flexed knee. There is a very small group of patients that have this instability without any injury. Usually this instability is associated with complete tears of the ACL (anterior cruciate ligament) or PCL (posterior cruciate ligament) One in five of posterolateral corner injuries are isolated to the PL corner (no ACL or PCL injury) The main treatment options for posterolateral knee injuries depend upon the grade of instability (grade I through grade III), acute versus chronic injuries, functional deficits, and whether there are any other associated ligament injuries concurrent with the posterolateral corner injury.

Most patients that have the feeling that their knee is buckling on a regular basis need surgery to stabilize the knee. This surgery is not arthroscopic. The surgeon makes a 4-5 inch incision on the outside (lateral side) of the knee and routes a donor tendon thru the tibia, around the back corner of the knee and attaches the donor tendon onto the lateral femur. The knee is braced with limited motion for 2 months. Most patients fully recover and return to normal activities.

Here is a link with an extremely technical description of the problem with diagrams and pictures of the procedure - not for the feint of heart- http://www.orthosupersite.com/view.asp?rID=28404

Unicompartmental Knee Replacement on NBC news

2009-02-05T23:22:00.004-07:00

Brian William's Nightly News Program focused on a computer guided unicompartmental knee replacement procedure that more patients are becoming interested in. The clip shows how computer-aided navigation can help a surgeon provide a custom fit replacement. Unicompartmental joint replacement is a good option for younger patient like the dentist in this piece that have bone-on-bone rubbing on just one half of the joint. He fully recovered after 5 months. (clip is 2 minutes, 20 seconds).

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-Guest post by Branden