Lumbar Spinal Fusion Procedures: The Last 100 years

January 4th, 2010

 

by Richard J. Nasca M.D.

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

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

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

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

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

Posted in Spine Surgery | 1 Comment »

Ischemic Optic Neuropathy (ION)

November 26th, 2009

 

 

 

by James W. Ogilvie, MD

 

Ischemic optic neuropathy (ION) is a disorder than can occur following surgical procedures. There is partial or complete loss of vision as the result of a vascular insult. It has several possible etiologies including thrombosis of the central retinal artery most commonly associated with giant cell arteritis. Direct trauma to the orbit and cortical blindness must also be considered. ION has also been reported with acute non-surgical blood loss and the use of Viagara™. Hippocrates gives an account of someone with acute hematemesis who subsequently lost their sight, perhaps the first report of ION.

           The least common and most enigmatic cause of post-operative vision loss is an ischemic episode to the optic nerve heads which are supplied by the short posterior cilliary arteries. The diagnosis of ION is made by fundoscopic examination of the eye in someone who reports a visual field defect following surgery. Emboli in the retinal vessels (posterior ION) can be visualized while in anterior ION (That which occurs anterior to the cribriform plate.) there are no initial diagnostic findings. After several months there is visible atrophy of the optic nerve heads resulting in a pale retina.

Because there may be effective therapies for other causes, it is important to differentiate ION from other etiologies of visual loss. An ophthalmologic consultant can accurately make the diagnosis. To date there is no effective treatment for anterior ION. Many therapeutic trials have been performed including the use of steroids, osmotic agents, hyperbaric oxygen, vasodilators and surgical decompression, all without benefit. There may be some spontaneous improvement in visual fields, but recovery from no light perception is very rare.

The causes of ION are not well understood, but acute blood loss is the most constant finding. ION has been reported with surgery in the supine, sitting and prone position. Prolonged spinal surgery in the prone position is the other commonly reported factor. Long surgical procedures resulting in facial edema when accompanied by hypotension or low hematocrit is often encountered in cases of ION. While atherosclerosis or diabetes may be predisposing factors, the relationship has not been studied in a scholarly fashion and ION has been reported in adolescents undergoing scoliosis surgery.

There is speculation that with acute blood loss there is an idiosyncratic response from released endogenous vasoconstrictors which may cause vasospasm of the short posterior cilliary vessels. It is not a sympathetic nervous system response due to the fact that sympathetic nerves do not supply the short posterior cilliary arteries. There may also be a congenital predisposition to ION due to a reduced ratio of capillary vessels to optic nerve heads. Unfortunately, there are no pre-operative tests to identify those with an increased susceptibility to ION.

Prevention of ION is clearly preferable. Reducing facial edema with the use of the reverse Trendelenburg position, limiting the use of crystalloids for fluid resuscitation and avoiding hypotension or anemia may lessen the incidence of ION.

ION frequently results in a medical liability action. If there are irregularities in the anesthetic record such as prolonged anemia or hypotension, use of large amounts of crystalloid for fluid resuscitation resulting in facial edema or improper patient positioning, the surgical team is often held liable. The issue of informed consent is often raised. What responsibility for discussing visual loss lies with the surgeon and anesthesiologist? There are no absolute answers to this issue, however this question should be settled long before discovery depositions are taken, preferably prior to the surgery itself.

 

 

     The guest author of this article for OrthopaedicList.com is Dr. James Ogilvie, a board certified orthopaedic surgeon.  He is Professor, Department of Orthopaedic Surgery, at the University of Utah in Salt Lake City and Professor Emeritus, Department of Orthopaedic Surgery, at the University of Minnesota in Minneapolis, MN. He is Staff Surgeon / Attending Staff at Shriners Hospital Intermountain Unit in Salt Lake City.

 

     A more detailed article on ION by Dr. Ogilvie can be found by clicking on the following link to it in the October 2009 issue of the American Academy of Orthopaedic Surgeons newsletter “AAOS Now”.

Posted in Complications | 1 Comment »

The Looming Total Joint Replacement Surgeon Shortage

November 17th, 2009

by Scott S. Kelley, MD

The difference between a good total joint and a great total joint replacement is initially small, but over time the difference can be significant.  A good total joint might last 10 years, but a great total joint could last 30 years.  Being a total joint surgeon is a profession with little or no room for error with every single hand movement. The procedures are demanding and the patient population is complex.  

 

Now, imagine this: The number of total joint replacement surgeons in the United States is cut by over 40 percent. The patient’s option for a surgeon is limited due to demographic or insurance restrictions.  This becomes a significant problem if the joint replacement fails because the subsequent surgery is much more complicated; therefore, fewer surgeons are willing to manage the revision.

 

Unfortunately, this could be the future of total joint replacement surgeons in America. Orthopaedic residents generally are not going into joint replacement fellowships because of this very issue.  We are 50% filled at best, during a time when we need to be increasing in size. Nationally there is a huge number of impending failures looming. Given the current state of our country, this issue is only going to get worse within the next 5-10 years.

 

The reimbursement for a single joint replacement surgery has been cut by over 65% in the last ten years.  This isn’t an issue for most surgeons currently in practice; however it does limit the amount of resources they can offer patients.  For example, try calling a doctor’s office and getting an actual person on the phone; these cuts affect everything from the number of front desk employees to the quality of care the surgeon is able to provide.

 

Cuts of over 65% in 10 years are now being followed with further cuts.  Understandably this makes doctors in training nervous.  Performing this surgery is stressful and I’m afraid it just isn’t worth it for younger doctors considering a specialty surgery career, particularly in joint replacement.

 

 While prevention and patient education remains a goal of all healthcare providers, it does not overshadow the current epidemic that is facing our society with respect to osteoarthritis and its surgical treatment options: the reality is that patients will continue to want the best in surgical care from the best providers.

 

Please click on the following to see a video entitled “Access Denied:  The Approaching Shortage of Specialist Doctors” and use it to educate your patients on the future of specialized care.  Although it’s a bit biased, it does clearly state the facts. 

 

Dr. Kelley, a third generation surgeon, is a graduate of the University of Iowa School of Medicine.  He performed his orthopaedic residency at the Upstate Medical Center in Syracuse, NY and his fellowship in Adult Hip and Knee Reconstruction at the Mayo Clinic in Rochester, MN.  He is a founder of the North Carolina Orthopaedic Clinic in Durham, NC, an affiliate of the Duke Medical Center where he is a Clinical Professor of Orthopaedic Surgery.  He has authored numerous scientific papers, serves as editor of medical journals, and is a member of a number of prestigious medical organizations.

 

 

 

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Stopping Healthcare-Associated Infections

November 14th, 2009

by Barbara Dunn

When someone develops an infection at a hospital or other patient care facility that they did not have prior to treatment, this is referred to as a healthcare-associated (sometimes hospital-acquired) infection (HAI).  According to the World Health Organization (WHO), at any point in time, 1.4 million people worldwide suffer from infections acquired in hospitals.

As part of an ongoing commitment to quality care and infection prevention, nationwide doctors and hospitals are partnering with Kimberly-Clark to deliver continuing education programs on healthcare-associated infection (HAI) prevention to staff and management Whether you’re a healthcare professional, patient, or visitor , the most effective way to keep HAIs down to a minimum is to wash your hands or use an alcohol-based sanitizer.

Please view the informational video at this link.

For more information please go to the Not on My Watch campaign.

Barbara Dunn was born in Jersey City, New Jersey, worked as an interior designer in Manhattan, then moved to Hawaii where she worked for a production company before moving to Arlington and reinventing herself as a PR executive.

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Marketing through Service: Double the Benefits

October 24th, 2009

by James D. Hundley, MD

            Some doctors think that “being a good doctor” is all that is needed to get patients to come see them.  That might work over a long period of time, but unless one is in an extremely underserved location, that is not likely to be enough.  Patients and referring physicians have to know of you to schedule visits or refer patients to you, so some way of getting the word out is essential to having a busy practice.  Even when one is currently busy, complacency could have negative future consequences.  Surgeons need a constant flow of new patients to maintain an optimal case load.  So, if you agree that marketing is important, how do you best go about it?  Do you do it by giving money to a marketing agency or could you do it by giving of yourself?  Neither way is cheap since giving of oneself takes time away from family, play, and work.  On the other hand, when you give of yourself in service, you’re likely to get a lot more back than you invest. 

Current wisdom seems to be that marketing one’s practice is best done through paid ads in newspapers, magazines, radio, television, yellow pages and so on.  I do not think that that is the best way to get the word out.  Anyone can say virtually anything in paid ads, so how is the potential patient supposed to know who he or she is really getting in his or her doctor?

            During my over thirty years of orthopaedic practice, I had success with marketing through service and relationships.  By this I mean giving of one’s time and talents in a variety of ways.  In every case, I tried to be more than just a member of an organization or cause.  As noted above, you don’t get much back if you don’t put much in.  Here are some examples:

 

Local Marketing

1.      I was able to become the volunteer team physician for a local university.  The work was a pleasure and much more extensive than outsiders ever imagined, but when they saw me on the bench at basketball games, many figured that I knew something about sports medicine.  The same thing works with high schools and community colleges and the need is great.

2.      The Rotary Club was a great way to meet business leaders around town.  By befriending them, they tended to call me when they or their families had orthopaedic problems.  Their employees often asked their bosses who they went to and followed suit.  The Rotary Club is but one example of many civic clubs and organization which bring you considerably more benefit than you take to them.

3.      Church is a great way to meet people.  Marketing is clearly not the reason one should join and attend a church, but doing so clearly has earthly benefits.

4.      Befriending the nurses in the operating room and on the wards can be a huge benefit.  That is not to mean that one cannot demand excellence, something that you should do.  All it takes is to treat them with respect and recognize that they bring significant knowledge to the care of your patients.  By making them partners, you get a more positive effort in behalf of your patients and the likelihood that they will both come to see you and send their friends and family, too.  Non-medical people often ask those in our profession for suggestions as who to see.  If I ever want to know if a surgeon is any good, I ask an OR nurse.  If they think you’re a good surgeon, and a good person, they are likely to send the people they care about to you.  If they dislike you, they’ll guide them elsewhere.

5.      By being appointed to the local library board (one of several), I had a fulfilling service experience and met an entirely different group of people.  It doesn’t matter what boards you serve on; it just matters that you serve.

6.      By working with the local medical society and ultimately becoming an officer, I met many local physicians whom I probably would have never met.  It makes a positive difference to physicians to refer their patients to someone they know and feel that they can trust. 

7.      Writing articles for the local newspaper makes one an instant expert in the eyes of many readers.  No matter the subject of the article, having published it makes many more people know your name and more likely to call you.  You can always pay for an ad, but news outlets are often looking for items of interest and happy to accept articles written by doctors.

8.      Word of mouth is probably the most powerful marketing tool you could possibly employ.  You can’t control it like an ad, of course, but if you consistently treat patients in their best interests and get reasonably good results, you will have unleashed a marketing force that is among the most effective.

 

Statewide Marketing

1.      Without expecting it, I found that working with our state orthopaedic society brought significant benefits to my practice.  When someone from my city was injured elsewhere and the orthopaedist who took care of them in some other city sent them to someone they knew (i.e. me) to complete their treatment or follow-up, it enhanced my reputation at home.  People talk, and this kind of talk is good.

2.      Also without any expectation of return, I learned that working (fund raising in my case) with my medical school and residency program (both within the state) enhanced my reputation at home.  When there is friendship and mutual respect between you and a professor of orthopaedics who speaks well of you to patients from your home town, they take note, and they tell their friends.

 

None of the above activities will do anything other than get more people in your door.  Once they get there, it’s up to you to properly take care of them, and that includes way more than surgical competence.  The three “A’s” (ability, affability, and availability) must be observed.  That applies to their entire experience in your office and the surgery center or hospital.

Let’s face it.  Patients generally have no good idea as to an individual surgeon’s abilities.  They have powerful perceptions, but they are not based on objective data.  If you consistently treat patients in their best interests and treat them with respect, they will keep coming back.  First, of course, you have to get them to come see you at your office.

So, if you’d like to increase your patient load without spending more money, you might just try marketing through service and relationships.  Not only is your practice likely to benefit, but the personal benefits of gratification and personal growth that incur from altruism beyond your daily medical practice may pleasantly surprise you.

 

 

 

Dr.  Hundley is a recently retired orthopaedic surgeon with forty years of experience.  He is the president and a founder of OrthopaedicList.com.

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Posted in Marketing | 3 Comments »

Implant Identification: An Opportunity for You to Participate

September 21st, 2009

 

by James D. Hundley, MD

 

                Having been in the orthopaedic profession for a long time, I have occasionally been confronted with an implant that I did not recognize and either did not have enough time or was unable to find out what it was.  Who hasn’t seen or heard of a bent femoral rod from trauma?  How about the intramedullary rod that had been in a femur for thirty years and had to be removed for a total knee replacement?  There have been a few knee and hip prostheses that had been implanted at “Elsewhere General” and needed to be revised.

                When I looked for a source that listed implants, I couldn’t find one.  That’s when OrthopaedicList.com was conceived.  It has proved to be immensely popular and useful for finding sources of implants, but we needed more.  You still had to know what you were looking for.  The next evolution brought “X-Ray Identification”.

                As orthopaedic surgeons and operating room nurses know only too well, removing implants can be tricky and is not always as easy to do as the x-ray might “suggest”.  Various rods have a variety of cap screws, removal threads, locking screws, etc.  You must have compatible instruments.  If you are revising a total joint replacement implant and don’t need to revise all components, it is essential to know the brand and model of the device.  That way you can match compatible components and preserve that which seems better left in place than removed.

                It’s always good to get the operative notes from the original surgery, but too often they don’t describe the implants.  The best source I’ve seen are the implant package labels that the OR nurse affixes to the operating room record, but they are not always available.

                For these reasons, at the suggestion of an orthopaedic professor, we started collecting x-ray images of identified implants on OrthopaedicList.com a few years ago.  Since this is something that will always be evolving and since we wish to provide free access to our colleagues all over the world, we chose the Internet as our venue.  Our library of implants has grown quite a bit, but to reach its true potential it needs to grow a lot more.  To do so, we need your help.  Why would you wish to go to the trouble?

1.      a. Prognosticators say that more and more devices will be implanted in younger as well as older patients.  Many will live into old age.  When the time comes to do something, records may be unavailable, the surgeon may no longer be in practice, the surgeons and product representatives who could  recognize these implants may be gone, and so on.  By going to our library of X-Rays, you at least have a fighting chance of figuring it out.

b. Please remember that what is familiar to you in your time and locale may very well be unfamiliar to someone else in another place or time.  Thus, we are not just looking for what you consider uncommon, but we’re looking for what you implant in your everyday practice.

           c. Some implant companies have their own library of images of their implants, but they are predominantly specific to their implants and not necessarily available to us.

3.      Privacy rules are making it harder to obtain records, even with signed releases from our patients.  I know about that from experience.

4.       Our population is aging and people move around.  There will be more and more people with implants.  Add those and you’ll realize that a growing number will need second surgeries in places different from the original hospitals.

5.      The educational benefit has been an unanticipated bonus.  We have word that nurse and technical schools use our images to train their students.  We hear that medical schools in some countries do the same.  We even know of at least one large orthopaedic manufacturer who uses our service to train their new representatives.  Furthermore, surgeons can send their patients to the site to see what various implants look like, including some cases that they have performed.

6.      Those who give presentations need illustrations for their slides.  You/they can copy the images from X-Ray Identification (soon to be renamed “Implant Identification”) for those presentations.

7.      We will make a donation to the Orthopaedic Research and Education Foundation in honor of those who submit images of x-rays.

8.    You can post “unknowns” yourself in hope that our colleagues will help you identify your inherited, troublesome implants.

 

So, how does one submit an x-ray?  Go to www.orthopaediclist.com and “roll over” “X-Ray Identification” (or “Implant Identification” if the change has been made) on the blue navigation bar near the top of the page.  Click on “Submit an X-Ray”.  The rest should be easy.  If you have problems, please let us know at info@orthopaediclist.com.

Oh, how about patient privacy?  Before submitting images, please crop out any information that may identify the patient.  That way we protect patient privacy.

Thanks for your help.  We’re all in this together to the benefit of our patients.

 

 

Dr.  Hundley is a recently retired orthopaedic surgeon with forty years of experience.  He is the president and a founder of OrthopaedicList.com.

 

Posted in Orthopaedic Radiology | No Comments »

Local Antibiotics in Prophylaxis of Surgical Wound Infections

August 22nd, 2009

 

by Laurence E. Dahners, MD

 

In 2007 we published an animal study (Yarboro S, Baum E, Dahners L: Locally Administered Antibiotics for Prophylaxis Against Surgical Wound Infection. Journal Bone Joint Surgery 2007 89(5)) documenting that injecting gentamicin into contaminated wounds after closure of the incision results in several orders of magnitude reduction in bacteria counts as opposed to systemic cephalosporins such as are usually given to prophylax against infection. This results in high concentrations in the wound cavity which are not achieved by IV administration and by injecting it after wound closure it is not removed before closure like antibiotic irrigation solutions. It worked significantly better than sustained release pellets at reducing bacterial counts. I have incorporated this into my trauma practice by injecting (80mg gentamicin in 40cc saline, inject enough to fill the wound) a gentamicin solution after the wound is closed and been very pleased with the reduction in the numbers of infections, especially in open fractures. Data that we published in the August 2009 JBJS suggest that systemic cephalosporins and local gentamicin have a large synergistic effect, so I would recommend doing both.

 

 

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

Dr. Dahners et al published “Better Prophylaxis Against Surgical Site Infection with Local as Well as System Antibiotics.  An in Vivo Study” in the August 2009 issue of the Journal of Bone and Joint Surgery.

Posted in HealthCare-Acquired Infection Prevention | No Comments »

Optimal Bone Saw Blade Design

August 7th, 2009

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

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

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

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

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

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

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

 

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

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Nicholas Andry’s Symbolic Tree

August 2nd, 2009

 

by Douglas W. Kiburz, MD

Nicholas Andry    Lyon 1658 – Paris 1742

 Nicholas Andry holds an important place in the history of orthopaedics and medicine as it was Andry who first used the word “orthopaedics” in a book published in 1741.  Within the text he illustrated the “crooked tree” which has become the symbol for many orthopaedic organizations around the world.  Although many related agencies have taken to modifying or customizing the tree, the essential design remains.

 

Andry was born in Lyon in 1658 and started his studies in theology but was drawn to the field of medicine.  In 1697 he defended his thesis:  The Relationship in the Management of Diseases Between the Happiness of the Doctor and the Obedience of the Patient.  He became well known for his stand against the “bleeding barber surgeons” and worked tirelessly to limit their venues.

 

His fellow faculty members depicted him as “superb, spiteful, confused, scornful, irascible and jealous” as described by R. Kohler in the European Orthopaedics Bulletin.  Andry was creative and prolific in his writings.  In 1700 he wrote his first book in which his explanations earned him the title “Father of Parasitology”.  At the age of 80 he published his famous work L’Orthopedie, a two volume set, in Paris in 1741 and it was translated in Brussels in 1742, London in 1743 and Berlin in 1744.

 

The book had artistic chapters on external proportions, methods of preventing trunk and spine deformities and had suggestions for physical therapy.  In a section addressing limb deformities, Andry recommended a bent leg be corrected by bandaging it to an iron plate as was commonly done to straighten the crooked trunk of a sapling.  From there came the orthopaedic crooked tree symbol, which has stood the test of time, translation and modernization.

 

Andry died in Paris at the age of 84 not long after having written his famous volume L’Orthopedie.  Kohler reminds us that Nicholas Andry neither deserves to be scorned nor to be revered.  “He produced fundamental ideas on methods of prevention, the plasticity of the child and the importance of gymnastics” and was known for his astute observations and colorful personality.  Few of Man’s whims or drawings or scribblings have survived to become as internationally recognized as the “Tree of Andry”.

 

 

Dr. Kiburz is an orthopaedic surgeon practicing in Sedalia, MO, USA and specializing in foot, ankle, and arthroscopic surgery.  He is also an accomplished sculptor who has produced a three-dimensional, copper interpretation of the 1741 “Tree of Andry”.

Posted in Orthopaedic Art | No Comments »

Osteoporosis

August 2nd, 2009

 

 

by Rebecca Yates, CNM, MN 

 

            Osteoporosis is the most common bone disease in humans. It is a disease characterized by low bone mass and structural deterioration leading to bone fragility and increased risk for fracture of the spine, wrist, hip, and other bones.  Currently 1.5 million Americans experience an osteoporotic fracture each year which represents 700,000 vertebral (spine) fractures, 300,000 hip fractures, and 250,000 wrist fractures. The number of people with osteoporosis and the resulting fractures are expected to increase significantly in the next 20 years. Every year the healthcare costs related to osteoporosis increase. In 2000 in North Carolina alone the healthcare costs for osteoporotic fractures was $455 million; the projected amount for 2025 is almost $800 million.

            The consequences of osteoporotic fractures are serious. Approximately 20% of those who suffer a hip fracture will die within the first year post-fracture. Half of those who experience a hip fracture will never be able to return to their previous level of physical function. Vertebral fractures result in chronic pain, respiratory and digestive problems, changes in body image and physical function, and difficulty fitting into usual clothing.  An osteoporotic fracture is a significant risk factor for another fracture within a year.

            One of the major risk factors for osteoporosis for both men and women is age; women are more affected by this disorder than men once they go through menopause and lose the hormone, estrogen. One in two postmenopausal women will experience an osteoporotic fracture in her lifetime. Ethnicity plays a role also as those of Caucasian and Asian descent are at greater risk than those of darker skin races who have heavier skeletal structure. Genetics influence individual skeletal development; therefore, family history of osteoporosis and non-traumatic fracture are risks. Other risks for osteoporosis include: low body weight, inadequate calcium and Vitamin D intake, inadequate physical activity, excessive alcohol intake, smoking,  long-term use of steroid medications, and the presence of certain medical conditions.

            The skeleton is living tissue that is being continuously “remodeled” through a process of cells which destroy old bone and other cells that build new bone. This process is balanced in the young adult; however, beginning in the third decade bone begins to be slowly lost. This process accelerates with certain conditions, such as loss of estrogen in women, certain medical conditions, use of some medications, and nutritional factors. The “bone building” cells can no longer keep up with the amount of bone that is being removed.

            Osteoporosis is diagnosed by DEXA which stands for “dual-energy x-ray absorptiometry”, a quick, painless, minimal radiation test which evaluates the density of the mineral in the bone. The results of the test help predict fracture risk by demonstrating whether the bone mineral is normal, low, or in the osteoporosis range. Another tool to help predict fracture risk is called FRAX which utilizes data about certain known risk factors to generate the 10 year probability of fracture.

            Adequate nutritional intake of calcium and vitamin D is critical to bone health; studies show that intake of both of these nutrients is inadequate in most American diets. It has been recognized that most people are vitamin D deficient; vitamin D is essential for the absorption of calcium and is critical to other body functions. Supplementation of both calcium and vitamin D can compensate for daily dietary deficiencies.

            Exercise, particularly weight-bearing or resistance exercises, such as strength training with weights or machines, is important for bone and muscle strength. It has a positive effect on bone growth and improves balance and muscle strength which improves balance and decreases fall risk.

            If nutrition and exercise fail to maintain bone health, pharmacologic therapy is available and proven to improve bone density and decrease fracture risk. One category of medications is the bisphosphonates which include Fosamax, Actonel, Boniva, and Reclast. These medications help to slow bone loss. For women, hormone therapy with estrogen may be used for osteoporosis prevention if she also needs estrogen for menopausal symptoms. Evista is a medication called a SERM (selective estrogen receptor modulator) which acts in a similar way to estrogen on bone but is not an estrogen. Forteo is a unique medication that actually helps to build new bone very rapidly and is indicated for people with severe osteoporosis or prior fracture.

            Once osteoporosis is present, early diagnosis is critical followed by any needed changes in nutrition and exercise. A healthcare provider can recommend the appropriate regimen of pharmacologic therapy.  Fortunately osteoporosis is a preventable disorder!! By practicing proper nutrition and participating in exercise that promotes bone health, bone loss may be prevented. When low bone mass is detected early, lifestyle changes and pharmacologic therapy can prevent progression to osteoporosis and significantly reduce risk of fracture.  Osteoporosis does not have to be an inevitable outcome of post-menopausal status in women and aging for both genders.

            The North Carolina Osteoporosis Foundation (NCOF) is a non-profit organization whose mission is to raise awareness of osteoporosis through education with a particular emphasis on prevention. In 2008 the NCOF funded six educational projects for consumers around the state. In addition to funding organizations to provide education about osteoporosis, NCOF also has a Speakers Bureau of knowledgeable individuals who can participate in community events.

           

 

 

 

 

 

 

 

Rebecca Yates, CNM, MN is in private practice in Albemarle, NC and is a member and the secretary of the Board of Directors of the North Carolina Osteoporosis Foundation.

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