Doctor Tarlow on Knees - The Lighter Side

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

2009-06-28T19:28:00.005-06:00

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

2009-06-07T12:31:00.005-06:00

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 ?

2009-05-30T14:24:00.007-06:00

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).

Visit msnbc.com for Breaking News, World News, and News about the Economy

-Guest post by Branden

ACL Reconstruction of the Knee: Autograft better than Allograft

2009-01-04T22:12:00.014-07:00

ACL Reconstruction restores knee stability and allows athletes to return to their desired sports activities. Two recent studies, one published in 2007 and one in 2008 questions the use of allografts in patients planning to return to sports prior to 1 year after surgery (one study defined younger as under 25 and the other under 40).

My clinical experience in the last 3 years supports the observation that allograft ACL reconstructions fail at a higher rate than autograft ACL reconstructions in younger patients returning to "aggressive" sports. I have noted that younger knees treated with allografts (tibialis tendons) combined with aggressive rehab with return to sport at 6 months have a higher re injury rate than similar patients treated with either patellar tendon (cartoon upper left) or composite hamstring autografts (photo upper right) and similar return to sport programs.

The reason for this observation is unclear but may be due to younger patients having a more active cellullar immune response which leads to allograft resorption or allograft healing times are simply longer than autograft healing times.

More clinical observation and study needs to occur to validate or disprove these findings. At this time these are only preliminary observations. However, because of my observation of autograft successes and allograft failures in 20 + years of practice I will recommend autograft reconstruction for most patients. Both the surgeon and the ACL patient want to have a ONE successful knee reconstruction and agree that graft failure and revision surgery is to be avoided if at all possible. Here is a link for more detailed information on ACL reconstruction.

Minimally Invasive Knee Replacement is Safe/Better: Refuting the Wall Street Journal

2008-10-28T14:42:00.010-06:00

The October 14, 2008 edition of the Wall Street Journal published an article entitled "New Doubts About Popular Joint Surgery". The following excerpt from the WSJ raises issues concerning Minimaly Invasive Joint Replacement surgery (MIS).

"But patients aren't always told that minimally invasive surgery is more difficult to perform than a traditional operation. Because of the smaller incision, surgeons have a harder time seeing what they are doing. And because minimally invasive surgery has grown so fast, many doctors don't have extensive experience performing the complicated procedure."

As an experienced MIS Knee Replacement Surgeon I completely agree with the above quoted comments. However, the other side to the story is that experienced surgeons using computer surgical navigation have patients with consistently excellent outcomes and complication rates as low or lower than traditional joint replacement surgeons.

I would like to address the three issue raised. First, "minimally invasive surgery is more difficult that a tradition joint replacement". There is a known "learning curve" of approximately 25 cases, after which most surgeons will have mastered the MIS technique. I have been performing MIS Total Knee Replacement since 2004 and to date have over 500 cases experience. The transition to MIS replacement will occur with time and can be compared to the transition in sports medicine from open "traditional" knee and shoulder surgery in the past to current arthroscopic treatment for most knee and shoulder injuries.

Secondly, "because of the smaller incision, surgeons have a harder time seeing what they are doing". Using Computer surgical navigation intraoperatively or computer generated surgical cutting blocks preoperatively provides the Minimally Invasive Joint surgeon with the information needed to accurately place the new hip or knee joint using the smaller incision. Computer technology more than overcomes the exposure issue raised in this second point. I personally do not perform MIS Total Knee Replacement unless I have computer navigation or computer generated cutting blocks.

Third, "because minimally invasive surgery has grown so fast, many doctors don't have extensive experience performing the complicated procedure". Every major city and some smaller towns have compentent, experienced minimally invasive joint replacement surgeons. As a patient, do your research and find the well trained, experienced minimally invasive joint replacement surgeon and you will often times be rewarded by a faster recovery and a less painful experience while getting all the long term benefits of traditional total joint replacement.

Patient Matched Total Knee Replacement - The Next Great Thing for Knee Replacement Surgery

2008-10-08T18:21:00.005-06:00

Computer Design is utilized to advance Total Knee Replacement Surgery. Patient specific anatomic data derived from MRI scans and long standing knee xrays are used to fabricate custom surgical instruments (cutting blocks). The custom blocks (see photo) are applied to the patient's bones for Patient Matched Total Knee Replacement, which precisely sizes and positions the knee components. This represents an improvement on Computer Navigated Surgery because the computer is now being used prior to surgery to pre plan the bone resection using a three dimensional model. This results in placement and sizing of the total knee specifically for each patient. The surgery is customized and the placement of the knee components are precise. This Patient Matched technology is only available at limited locations in the U.S. (Dr. Tarlow is authorized to use this technology at Scottsdale Thompson Peak).

This Smith and Nephew technology may be superior to the Otis Med technique because the Patient Matched Total Knee Replacement restores the knee to the "gold standard" neutral mechanical axis (straightens deformed legs).

Patient benefits with the Patient Matched Total Knee Replacement include MIS (minimally invasive surgery) techniques, reduced operative and anesthesia time, shorter hospitalization, and speedier recovery.

The Journey Knee design is the first and only of it's kind. Designed from the ground up from a clean slate by a team of engineers, knee rotation, translation and flexion are restored to near normal parameters. Modern design tools created a knee with unique design features resulting in superior stability, strength and flexion. Patients remark the Journey knee provides better knee motion and feels more like a normal knee compared to other knee designs.

The use of Oxinium as the metal for the Journey knee further improves the Patient Matched Total Knee, making this ideal for the younger and more active patient. Oxinium is a metal with a ceramic surface that has outstanding wear resistance. Oxinium, with it's superior wear characteristics, may be a superior material for Total Knee Replacement in the younger, active patient.

Medicare Dilemma for Orthopedic Surgeons

2008-06-13T13:35:00.004-06:00

Yesterday's notice from the American Academy of Orthopedic Surgeons:

"As expected, today’s Senate vote on whether to consider the Baucus Medicare package failed. As both parties begin to negotiate compromises on their respective bills, we urge Senate leaders to work on a bill that can enjoy broad bipartisan support in the Senate and be enacted into law before the 10.6 percent cut goes into effect on July 1, 2008."

Medicare's physician payments have been spiralling downward since the 1990's. A recent Texas public survey concludes the reasonable surgeon fee for total knee replacement is $5000. In Arizona in 2008 the exact surgeon medicare allowed payment is $1412 (this is a "global fee" and includes day of surgery, hospital rounds, and all treatment for 90 days after surgery). This rock bottom reimbursement schedule has many orthopedic surgeons, including me, contemplating dropping Medicare from their practices. This is a direction I am reluctant to take. I do not want to restrict needed care for "America's Greatest Generation".

The current Medicare fee schedule fails to provide a high enough level of reimbursement for any orthopedist to run a financially successful practice. In reality, the Medicare segment of my practice is subsidized by having other payor sources. Deeper cuts in Medicare physician payment is on the near horizon. When these cuts occur physicians will take "evasive" action. Medicare is an all or none system. Doctors are either on the plan and accept Medicare rates or are off the plan and charge patients "market rates" that can be modified based on the patients ability to pay.

I predict in the next year experienced surgeons will leave the Medicare program (opt out) and choose a free marketplace to offset the rising costs that have been absorbed by physicians for the last 15 year.

Here is an excerpt of my letter to the Senate.

"As an orthopedic surgeon practicing in Arizona I provide medical care to our senior citizens. I continue to accept Medicare patients in my practice.
My Medicare participation allows these, "our greatest generation", wide access to care these patients have grown to expect. I am writing to urge you to pass a Medicare package that keeps intact current Medicare rates. Any cut in Medicare reimbursement will push me to opt out of Medicare participation. I will be unable to subsidize the costs associated with providing care to Medicare patients if the rates are cut any lower.

* The deadline for enacting a fix is quickly approaching;
* Allowing the cut to go into effect will have a detrimental effect on Medicare patient’s ability to access care;
* An 18-month positive update must be enacted to prevent physicians from leaving the Medicare program;
* Including a provision that moves the budget neutrality adjuster from Medicare work values to the Medicare conversion factor will help bring equity and fairness to Medicare payment calculations."

Please comment on this post. I want to know what you are thinking.

Minimally Invasive Surgery (MIS): Who is a Candidate for MIS Total Knee Replacement

2008-05-18T06:37:00.004-06:00

Here in the Phoenix - Scottsdale, Arizona area I am frequently asked by patients "Can you perform Minimally Invasive (MIS) Total Knee Replacement (TKR) on my knee ?."

My answer is I can perform Minimally Invasive Total Knee Replacement on most any patient but I choose to use the technique on the large subset of patients that benefit most from the technique. It is a surgical procedure that is more technically demanding and more time consuming than traditional Total Knee Replacement so I am somewhat selective on choosing patients for this method. By analogy, I would not buy a new Basketball for my 90 year old mother in law but I would for my teenage son who is on the high school basketball team. She would never use the basketball and he would use it frequently.

I always perform Minimally Invasive Surgery on the healthy, motivated, energetic patients who will recover fast because of their good health and motivation to get well fast. I rarely perform Minimally Invasive Surgery on unhealthy patients with multiple co morbidities (Diabetes combined with cardiac or respiratory disease combined with high Body Mass Index is a typical patient profile that comes to mind). The first example patient would take full advantage of having had this technique by discharging from the hospital in 1-2 days, be walking freely without a walker in 5-10 days, be driving in 10 days -3 weeks, be back to work in 2-4 weeks and be golfing or hiking in the beautiful Arizona desert in 4-8 weeks. The second example patient would recover but take 1-3 months to reach similar milestones.

Body mass index is sometimes a factor since some patients with high BMI have low energy. BMI alone is not a reason not to perform MIS Total Knee surgery.

A normal BMI is under 30 and defined as a six foot tall man weighing 215 pounds or less or a five foot six inch woman weighing 182 pounds or less.
Obesity (BMI 30-40) is the six foot man between 215 and 285 pounds or the five foot six woman between 182 and 240 pounds. Morbid obesity (BMI above 40) is above 285 pounds for the six foot man and above 240 pounds for the five foot six inch woman. (BMI tables are available online to calculate your own BMI). Minimally Invasive Surgery can be performed on the higher BMI patients. It always requires a skin incision 2-4 times longer than the incision in under 30 BMI patients. The longer skin incision allows the surgeon to "convert" the high BMI patient into a low BMI patient by retracting away the "extra" skin and subcutaneous tissue. However, the definition of Minimally Invasive Surgery Knee Replacement and the key factor allowing for faster recovery is not the size of the skin incision but the size of the deep or Capsular incision that allows the surgeon into the knee joint proper. Therefore high BMI patient can have Minimally Invasive Total Knee Replacement Surgery and enjoy the benefits of a faster recovery.

Returning to the question posed at the beginning of this post: Who is a candidate for Minimally Invasive Total Knee Replacement Surgery ? The answer is that most people are good candidates for MIS TKR as long as they are healthy, have a good energy level and are motivated to recover quickly.

National Standards to Rank Physicians Planned

2008-04-01T22:12:00.004-06:00

This recent article on a National Standard to Rank Physicans caught my attention. The political backdrop is fairly complex (and rancorous) but it drives at an important issue for patients: how do you pick a good doctor?

I would welcome a new system if its valid, reproducible, and accurate. It would be fantastic for patients to have that meaningful information to rely on when picking a doctor to treat a new illness or condition...informed choice.

How will I be rated? Surgical skill, patient management, outcomes, bedside manner? For the system to succeed, it needs to be flexible enough to go across specialties. The skills sets of a great anesthesiologist are much different than the qualities you need from orthopedic surgeon.

As an orthopedic surgion, i think the most important factors is judgement/ decision making. Do you know when to try one thing before the next, when surgery is necessary, etc. It's not just brain power. (Jerome Groopman discusses this at length his book "How Doctors Think", a great read for patients and physicians alike). The next most important trait is surgical skill. Again, I would welcome a system that could accurately, and reproducibly evaluate these important factors.

What factors do you use to rate your doctors? How do you go about finding a good one?

Otis Med: Shape Matching Custom Fit Total Knee Replacement

2008-02-24T11:23:00.002-07:00

There is a movement under foot that runs counter current to the time tested principles used to position the implants in Total Knee Replacement. This principle is called Shape Matched Technology (this phrase is a trademark of Otis Med). It allows for what Otis Med terms a custom fit Total Knee Replacement.

Here is an excerpt from the Otis Med site (http://www.otismed.com) :

Shape-Match™ Technology

OtisKnee™ is based on OtisMed’s patent pending, proprietary Shape-Match™ technology. Using sophisticated 3-D software, the Shape-Match™ technique optimizes the size and placement of the Custom Fit Knee™ before surgery, based on the patient’s own normal (non-arthritic) knee anatomy. From this very precise 3-D image, custom cutting guides are created to assist the surgeon in making very accurate bone cuts that are specific to the individual patient. This allows for a “customized” implant fit and placement. Prior to the availability of Shape-Match™ technology, surgeons have relied on experience and intra-operative judgment to correctly size and place the implant in the patient. END of OTIS MED excerpt.

In essence Otis Med uses MRI images of the diseased arthritic knee. The proprietary software then calculates how much of the joint surface has been lost in the arthritic knee, calculates how much to "put back" to restore the knee to it's normal, naturally given position and then provides the surgeon with custom made tools to restore the knee "back to normal". A key principle in the Otis Med technique is to restore the axis of rotation to the knee, and this can only be done by identifying the normal axis of rotation on the reconstructed MRI scans. This information is then provided to the surgeon by fabricating custom cutting blocks that are used to re sect the bone when performing an OtisKnee. This can not be accomplished with traditional Total Knee Replacement in the same manner as OtisMed, even if the surgeon uses Surgical Computer Navigation. Otis Med technique can only be used with Stryker and Biomet implants (because of the shape specific to these two brands of implants).

The debate, which is just heating up and should be spirited, will compare the merits of the totally new concept of precisely how to position the knee implants using the Otis concept, to the traditional technique of making every replaced knee straight (mechanically aligned to match a straight line running from the hip to the center of the ankle) and balancing the knee ligaments by releasing contracted ligaments and tightening stretched knee ligaments.

As I begin to analyze this radically new way to position knee implants I must say I am somewhat intrigued by the OtisMed rhetoric. Their concept places critical importance on the balance and range of motion of the knee, with axial alignment secondary (almost an after thought). Traditional technique stresses axial alignment above all else, with balance by ligament release important as well. Traditional technique, which here to for has been the dogma for positioning implants, boasts long term results with 90 % success rates 10-20 years after implantation. There are only a few peer review published articles supporting the Otis Med concept.

As they say, the jury is still out on the Otis Med principle. As a surgeon living in an ever changing, high technology world I believe I owe it to my patients, myself and my profession to study the facts for and against the Otis Med technique. Ultimately I will make an informed decision based on the best information available as whether or not to incorporate this technique into my practice of Knee Surgery.

Replacing Knees Sooner in Women May Enhance Outcome

2007-11-18T11:50:00.000-07:00

Conventional Orthopedic Surgical wisdom is to delay joint replacement until the patient is seriously impaired by their symptoms, even though on x-ray the patient's knee joint is destroyed by arthritis. This means delaying surgery for serious knee arthritis until patients can not walk more than a block or two, can only ascend and descend stairs one at a time, patients are limping and patients have sleep disturbance from arthritis pain. Additionally, conventional wisdom recommends trials of NSAIDS (ibuprofen like meds), physical therapy, bracing, steroid injections or Hyaluronic Acid injections (synvisc and the like).

The lead article in the November, 2007 Journal of Bone and Joint surgery challenges this precept and presents strong scientific evidence to support the conclusion to operate sooner on women with serious knee arthritis that have measured functional deficits. The article is entitled Disease-Specific Gender Differences Among Total Knee Arthroplasty Candidates and was done at the University of Delaware.

Arthritis of the knee has a greater effect on knee function and strength in women, reflecting a gender difference in the disease impact. This larger impact on knee function in women is manifest by lower quadriceps muscle strength ( large muscle group in the front of the thigh), longer timed up and go standing test, longer timed stair climb, and shorter 6 minute walk distance compared to men with knee arthritis.

The logical and yet revolutionary conclusion is that strength and functional decline should be closely monitored (this functional testing could be documented by a Physical Therapist) in women with knee arthritis and when worsening is observed, joint replacement should be carried out. In some cases this may mean joint replacement is done sooner (compared to using traditional standards for deciding on the timing of surgery) .

Minimally Invasive Total Knee Replacement Facilitates Recovery

2007-09-09T19:19:00.000-06:00

An article appeared in the July, 2007 Journal of Bone and Joint Surgery entitled "Minimally Invasive Total Knee Arthroplasty Compared With Traditional Total Knee Arthroplasty". The main author is Seth S. Leupold, M.D. from the Department of Orthopedic Surgery at the University of Washington in Seattle.

The conclusion of the article is that minimally invasive Total Knee Replacement seems to facilitate recovery after this operative procedure. The patients who had the minimally invasive approach demonstrated significantly better clinical outcomes with respect to shorter length of hospital stay, higher percentage of patients discharged to home instead of inpatient rehabilitation facility, less narcotic use at 2 and 6 weeks post operatively and less need for assistive devices to walk at two weeks after surgery.

The Journal of Bone and Joint Surgery is one of the most respected and credible orthopedic surgery publications. The journal was founded in 1903 and is the official journal of the American Association of Orthopedic Surgery. The guiding principle of the JBJS is excellence through peer review. There are high standards, professional review and rigid criteria that have to be met before an article is accepted for publication. This is one of the first unbiased articles to appear in a prestigious orthopedic journal confirming the benefits of minimally invasive Total Knee Replacement. Therefore I believe the appearance of this article in the JBJS is highly significant.

Like the author of this article, I began performing MIS Total Knee Replacement in 2004. And just as the author discusses in the quoted article there is a learning curve of at least 25 cases to become more familiar with the technique. Like the author I perform a number of these operations on a monthly basis so that I got the over the learning process in a 3 month period. Over the last 3 years I have performed Minimally Invasive Knee Replacement on most of the patients I treat surgically for knee arthritis.

The components that are implanted are the same for MIS and Traditional Knee Replacement. I always use Surgical Computer Navigation as I believe this improves the accuracy in component position.

In my experience 1 in 4 patients are discharged home after one night in the hospital and most of the remaining patients go home after 2 nights. It is less common for a patient to be hospitalized 3 nights or to be discharged to an inpatient rehab facility. Similarly 25 % of patients are walking without assist in a week and the 70 % are walking without assist at 2 weeks. Most patients are driving in 2-3 weeks.

The results with respect to mobility, knee motion, pain relief and function for activities of daily life after MIS and Traditional Knee Replacement seem to merge around 3-12 months after surgery, however the return of quadriceps strength seems to occur sooner in MIS patients.

In conclusion I found the publication of the article highly significant and supportive of the beliefs of my colleagues who are currently performing minimally invasive Knee Replacement. Surgeons using minimally invasive techniques for Joint Replacement do so because of the greater patient benefits with this procedure.

Airport Metal Detectors and Orthopedic Implants

2007-05-28T07:54:00.000-06:00

In my practice patients will ask whether their orthopedic implant will cause any trouble at an airport security checkpoint. Until now I had not been able to reference any scientific studies that have evaluated which implants would trigger the airport metal detector.

An article that recently caught my attention was titled "Detection of Orthopaedic Implants in Vivo by Enhanced-Sensitivity, Walk-Through Metal Detectors" and appeared in the April, 2007 Journal of Bone and Joint Surgery. This article will be of general interest to patients in predicting whether their implant will trigger extra scrutiny at a security checkpoint. Shown on the right is an xray of a stainless steel plate and screws at the knee joint. This is likely to be detected by the Airport Metal Detector because of the large size of the blade plate and screws.

Patients with Total Hip and Total Knee replacements are commonly given credit card sized identification cards to travel with. However, in reality these cards are not acknowledged by airport screeners. If you have an orthopedic implant in your body that is likely to trigger the Airport Metal Detector allow extra time (5-15 minutes) to pass through airport security. What my patients with Knee Replacements tell me is that their implant does trigger the detector, and they are taken to the secondary screening station. There they are "wand ed" to verify the cause of the Metal Detector alarm was in fact their artificial knee and then they are cleared through the screening area. Rarely is any other type of more prolonged and time consuming screening done.

In their study the authors looked at Hip replacements, Knee replacements, spine fusion hardware, and upper and lower extremity fracture repair rods, plates and screws and wire.

Xray of Total Hip Replacement (above). This has a 100% chance of triggering the Airport Metal Detector.

The findings are summarized here. As you read the findings keep in mind that detection rates will vary because of the following facts: 1. Different brands and models of detector machines will have variable detections rates. 2. Sensitivities of metal detectors can be influenced by local magnetic interference such as fluorescent lighting or from other medical imaging devices. Repeating this study in a different location, such as your hometown airport, may show different detection rates. However in general the following observations can guide you as to the likelihood of whether your orthopedic implant will trigger an airport metal detector.

Total Hip replacements were detected 100% of the time.
Total Knee replacements were detected 90% of the time.
Total Shoulder and wrist replacements were not detected.
Plates with screws were detected approximately 25% of the time.
Screws alone or wire alone or intramedullary rods alone were usually not detected.
Lower extremity implants were detected 66 % of the time.
Upper extremity implants were detected 17% of the time.
Spine implants were detected 14% of the time.

And the type of metal matters. Cobalt chrome and titanium were likely to be detected, while stainless steel was unlikely to be detected.

Photograph of Knee Replacement implants made of cobalt chrome (above). Total Knee Replacements are detected 90% of the time by Airport Metal Detectors.

I invited readers to submit their experiences navigating through security with orthopedic implants.