Saturday, February 26, 2011

Welcome Guest Blogger: Dr. John Parker

Margaret always said yes.  She was kind and thoughtful, she knew every single person in our small town, and she made the best chocolate chip cookies anyone ever tasted.  She was my grandmother, and she spoiled me like a grandmother should.

Family holidays and events were spent in her living room, where our large extended family would gather around her chair to share experiences and stories.  And she would sit - skirt gathered, knees prim - and bask in the pleasures of family.  

Over the years, however, I noticed one thing: Grandma Margaret rarely moved from her chair.  We would fetch whatever she needed - things from the kitchen, or knitting supplies from her downstairs sewing room.  As the years bore on, in fact, she moved less and less.

By the time she was 80, walking had become very difficult for her.  Everything hurt, she said.  Her knees hurt, her ankles hurt, her hips hurt.  And we had unwittingly contributed to her disability by catering to her needs with such regularity.

“Use it or lose it.”  Turns out, this simple axiom is right on.  

Today, I work in a busy orthopedic practice, and older patients make up a large part of my practice.  We replace their hips and knees, we fix their fractured bones, and we try to return them to as many activities as possible.  Because it’s that active lifestyle - the activities themselves, as well as the level of interest behind them - that keeps the older population engaged and contributing.  And they have a lot to offer.

Today’s mature population has great expectations.  Retirement for them is a beginning, not an end.  They look forward to spending their later years pursuing the activities that interest them, and they look to us to help them do so.  Mine is a rewarding field, to say the least. 

My favorite patients are the ones who remind me of my Grandma Margaret.  They want to enjoy the years ahead of them, but something - maybe a hip, or a knee - is holding them back.  They want to get up and go into the kitchen themselves, but it hurts to do so.  And I get to be the one to tell them: “We can fix that.” 

And after we fix their fractures or replace their hips, they come back with questions about which activities they can go back to again.  Can I walk?  Can I golf?  Can I work in the garden?

And I always say yes. 

John F. Parker MD is an orthopedic surgeon with Syracuse Orthopedic Specialists.  A native of Lowville, he is slowly adjusting to the tropical climate of Central New York.

Sunday, February 20, 2011

Birmingham Hip Resurfacing: Success in the Right Patient

By Brett Greenky, MD

Metal on Metal (MoM) hip replacement and resurfacing implants have been prominent in the news over the last several years.  MoM articulations have been attractive to joint replacement engineers because of the potential advantages of decreased wear when compared to metal on plastic hip (MoP) articulations.  The McKee-Farrar MoM implant of the 1970’s showed initial promise, but in the end resulted in much higher rates of failure compared to plastic and metal.  New advances in metallurgy (the science that deals with the physical and chemical behavior of metallic elements) have rekindled interest in MoM designs.  Laboratory simulations of implant wear have shown dramatic reductions in the overall volume of wear material in MoM hips compared to MoP, however, MoM articulations create many more wear particles (although smaller in size) when compared with MoP.   It still remains unclear if MoM will be superior to MoP for most patients.  Two implants have gained much attention in the lay media over the last 5 years, one in a positive and the other in a negative manner.  Birmingham Hip Resurfacing is emerging as a successful procedure in certain patient populations while the industry “recall” of a MoM Hip Replacement system is controlling overall MoM enthusiasm.  (**see implant photos at end of narrative**)

The Birmingham Hip Resurfacing was approved for use in the USA in 2006 based on an excellent track record largely from one center in Birmingham, England.  There, Dr. McMinn the implant’s surgeon-developer gained a cohort of high functioning patients with greater than 8 years of success using his second version of the implant. The first version of this implant developed failures at the 6-8 year mark after surgery.  Subsequent modifications of the manufacturing process resulted in preservation of high levels of Carbides in the Cobalt Chrome implants has now resulted in the new version having much better success. 

Hip resurfacing’s unique attraction when compared to traditional Hip Replacement is that the femoral head is largely preserved.  The femoral head (the uppermost part of the thigh bone) is reshaped and resurfaced in the procedure rather than removed and replaced with a manmade head in traditional hip replacement.  Theoretically, the femoral head bone that is preserved during the resurfacing procedure allows more options at a later time if additional surgery is ever needed.  It also permits the leg bones to accept weight in a more natural way than with the stem version of replacement. The rationale is that the less invasive resurfacing operation with its bone preservation will allow the operation to be performed on younger patients who will enjoy higher activity levels and if revision is ever needed, the surgery will be easier because the femoral head was preserved during the initial procedure.  The future will reveal whether these claims will be proven true.

In the United States, we do not have a National Joint Replacement Registry.  A registry is a data bank which holds the records for all joint replacement surgeries performed and tracks the results.  The database allows healthcare professionals to detect implant designs or surgical techniques that are underperforming at an early date!  Such registries have established and functional for decades in Australia, the United Kingdom and Sweden.  The registries in these countries have documented an excellent track record for the Birmingham device!  When applied to the correct patient and when the surgery is performed perfectly, the results are as good as any of the traditional hip replacement devices.  It is also true that patients, young men in particular, enjoy very high functional activities with the implant.  Whether the success in these patients is completely due to the Birmingham procedure itself, or if it should be attributed to “selection bias” remains to be seen.  Selection bias is a process in which the patients most likely to have high functional activities (irrespective of the type of operation performed) are getting resurfacings rather than the more invasive replacements, and thus making the resurfacing group look better rather than from actually from the superiority of the procedure or the implants used.

There have been other resurfacing issues illustrated both by the foreign registries, as well as our own experience here in the United States.  The resurfacing operation is somewhat larger and technically more difficult to perform than replacement.  There is a steep learning curve for the surgeon.  This is not an operation for the occasional hip surgeon, but rather for the Joint Replacement Specialist.  Postoperative fracture of the femoral neck (the flattened section of bone connecting the femoral head with the long part of the femur) occurs 1% of the time in the hands of the seasoned specialist, and much more frequently with the occasional hip surgeon.  Wear rates (the speed of material change due to wear) at the ball-socket interface are related to the alignment of the implants more in MoM implants than when compared with MoP interfaces. Orthopedic experts suggest that at least 30 cases are critical for the surgeon to gain the necessary surgical experience.  Both foreign registries and surgeon experience in the US have shown a much higher complication rate with resurfacing compared with hip replacement.  Experienced surgeons do have lower complication rates as do hospitals performing high volumes of these procedures.  The data also shows that the resurfacing operation is not for most women.  The complications are much higher in women even when under the care of the experienced surgeon.  The risk of needing a second operation within 3 years of a resurfacing procedure is 3 times higher for women than men.  This phenomenon has been noted in the registries maintained in Australia, England and Sweden. Here in the US, the same problems for women have been noted and reported by researchers at Rush University Medical Center in Chicago.  The etiology of the gender difference is not completely known.  Lower bone density in women (and older men) certainly increases the risk of the femoral neck fracture complication.  Smaller size hip sockets are also associated with higher rates of problems, and certainly women in general have smaller socket sizes.

Overall, the Birmingham Resurfacing surgery does have excellent results in the correct patient population.  Increasingly apparent is that the target population for this procedure is men below the age of 60 who want to continue with higher impact activities after the surgery.  Women candidates need bone density testing and consultation with an experienced surgeon to make sure they understand the increased risks.

Further Reading:

1)     Della Valle, et al. Hip Resurfacing Surgery Report, Rush University Medical
Center, Nov. 2008.  
2)     Meier, Barry. For Women, Red Flags About a Hip Device, the New York Times,

Birmingham Hip Implant
Metal on Metal Total Hip Implant

Sunday, February 13, 2011

A Lingering Memory from a Long Ago Day

By Dr. Brett Greenky

It was August 1990, the days when beepers simply beeped and cell phones housed a whole suitcase.  I sat in the emergency room waiting for the inevitable consequence of a smoldering Syracuse summer day. The sunset is especially appreciated in our city of long winters and gray skies. A cooling breeze arose as the heavy sun drifted lower, dragging a shadow across the cityscape.  The desire to be outside was irresistible.

A 19-year-old girl, home from work in the third floor apartment she shared with three friends, watched the sun’s descent as she waited for her roommates to arrive.  The last beads of the day’s perspiration evaporated as a new convertible drove up below her and she lingered on the fire escape.  A boy she knew distantly from school had stopped below her with a new red sports car.
“ You want to go for a ride?” he asked.
“No, I better not.  My roommates are coming home soon and we’re gonna go out tonight,” she replied.
“Come on, we’ll just go for a quick spin.  I’ll have ya back in 20 minutes.  I just got my first car, isn’t it slick?”
“Yea it’s really nice,” she admitted.  “I have to wait for my roommates.”
“Come on, you will be back before they even get home. Leave a note,” he gestured with a waving hand.
“Ok, but really quick cause I gotta be back in 20 minutes.”

            The stairs are always faster in the hospital; less competition than the elevator, and no unscheduled stops. 
            She lay on a stretcher, quite calmly actually, IV in place as I watched from the doorway. The ER Physician softly whispering to me the situation: 
o   No nerve function in either leg.
o   Hemodynamically stable.
o   Neck pain only, collar in place.
o   Foley catheter in and no blood in the urine.
o   Spine and pelvis X-ray being developed
No reason to go in there until I see the X-ray’s I thought, since questions will be asked, and the answers will depend on the films.  I wandered to the X-ray display and startled.  The films were all fine except the cervical spine.  She had bilaterally jumped facets at C5/6.

             The boney spine is like articulating armor around the spinal cord.  Think of a concrete embankment around a highway, protecting the traffic. There are a lot of entrances and exits in certain areas like downtown and long stretches of highway with few exits.  The spine is best protected in the long thoracic area (the part from your shoulders to your waist) by the stiff facet joints and the presence of the ribs.  As a consequence, traumatic injury in the middle of the thoracic spine is rare.  The cervical (neck) and lumbar (low back) parts of the highway have lots of exits and entrances for the nerves to the arms and legs.  In addition these areas need a lot of flexibility for motion. These areas are much more vulnerable to trauma.  The most risk exists at the junctions between stiff and flexible spine segments.  Where the flexible cervical spine meets the stiffer thoracic spine is especially at risk.
            Bilaterally “jumped” facets result in a 50% reduction of the spine diameter at that level.  Usually that pitches the spinal cord so much that permanent loss of nerve function below the level of injury is inevitable: quadriplegia.

            “Hi, I’m doctor Greenky, one of the bone doctors here at the hospital.  Do you have pain?”
            “My neck hurts but that’s it.  Why can’t I move my legs?”
            “You have an injury to your spine and your spinal cord in your neck.  It’s too early to tell about improvement right now,” I responded.
            “OK, but I have to work on Monday so I have to be out of here soon.”
            “I understand.  Can we call your parents and let them know you are here.”
            “I don’t want to call them. They will be mad I went for a ride in that car. I will tell them later next week when I’m all better and back to work.”

            The nurse and I checked the “bulbocavernous reflex” using the Foley catheter. This presence of the reflex represents the end of spinal cord shock.  If the spinal cord is in shock and not recovered then reversal of some, and in rare cases most, of the nerve deficit is possible.  The presence of the reflex means no recovery will occur.  Her reflex was present.  Our hearts fell.  Her quadriplegia was going to be permanent. I knew it immediately and felt a wave of nausea.  I smiled and held her hand.

            “We need to stabilize your spine with an operation.  We need to talk to your parents now.”
            “Ok, but they are going to be mad,” she reluctantly responded.
            “I know. My parents have been mad at me lots of times but they got over it,” I said.
            “How about moving my legs?”
            “It’s too soon to know for sure,” I answered again. “Lets take one thing at a time.”

            As I walked to the OR to book the case, a glimpse of the red sun slipping below the horizon left me with the feeling that a long dark night had just only begun.

Sunday, February 6, 2011

Reflections On My First Day

By Seth Greenky

Amidst the clutter of half-opened shipping boxes and the chaos of three young boys ages one, three and five happily romping in the configuration of boxes, furniture and other odds and ends as if they were secret tunnels deep within an enemy fort, I took a moment to reflect on what had been and what was yet to be.  Years and years of education, training and refinement of my clinical and diagnostic skills were now behind me, and I began to envision what the years ahead as an attending surgeon would bring.  I had just completed a yearlong fellowship in adult reconstructive surgery (joint reconstruction surgery) at the Cleveland Clinic and returned to Syracuse where I attended medical school and completed a residency program at the Upstate Medical Center.  Joining an established and diverse group of orthopedic surgeons here in Syracuse would afford me the opportunity to learn from experienced colleagues while launching my own practice as a joint replacement surgeon. I was grateful that I had a full week to make that mental and physical transition before I actually started with my new group.

My thoughts were interrupted by the persistent ringing of the telephone.  I searched for the source of the ringing until I successfully unearthed the phone from beneath a mound of action figures, stuffed animals, and miniature cars buried in the corner of the room.  As I shouted “hello”, afraid that I hadn’t reached the phone in time, I heard the voice of one of my new partners at the other end of the phone.  “Seth” he quickly replied to my greeting, “welcome to Syracuse.  Can you do me a favor?  I need you to cover the ER for me today.  Something unexpected has come up.  Don’t worry, I checked with the Emergency Room and nothing is going on.”  With that, the phone call ended.

A small wave of anxiety swirled inside me but I pushed it aside, recognizing that the likelihood of actually having to respond to anything was minimal.  When the phone rang again less than five minutes later, the thought that it could be the St. Joseph’s Emergency Room couldn’t have been further from my mind.  I heard the words multiple trauma, motorcycle accident, young guy, and open tibia fracture (the hallmark injury of high velocity trauma accidents).  Open fractures are surgical emergencies that require immediate surgical intervention to prevent infection and vascular compromise.  As a pit formed in the center of my stomach, I was out the door immediately and enroute to a hospital in which I hadn’t stepped foot in more than four years.

The 12 minute drive to the hospital was surreal, seemingly lasting an eternity, while simultaneously flying by in what seemed to be mere seconds.  For the first time ever, I am the surgeon.  Alone, on my own, and completely the end of the line. The reality of the phrase “the buck stops here” slowly sunk in.  It’s not that I hadn’t done a large number of these types of procedures; however, in my residency and fellowship I had been functioning under the comfort and reassurance that there always was someone else nearby to advise or assist me if needed.  Not in this situation.  I was headed to a new hospital in a new city to render emergency care to an individual who would be counting on me to make him whole again. 

After parking in what I later learned was a patient parking lot, I made my way into the building and was greeted by a guard who escorted me to the ED, undoubtedly wondering if I really was the doctor I presented myself to be.  The fact that his eyebrow arched as he introduced me to the charge nurse in the Emergency Room as well as the unspoken exchange between them signaled to me that they were more than slightly skeptical of my identity and my intent.

I next found myself looking into the eyes of a young male patient writhing in pain and surrounded by concerned and anxious parents.  I would later learn that he was a college freshman and a baseball star on the verge of greatness, but for that moment he was a terrified kid in requiring my immediate aid. The intensity of his pain filled eyes begged me to reassure him that everything would be fine.  We needed to get to the Operating Room as soon as possible.

The next several hours passed in a blur of activity and uncertainty.  We were in the Operating Room in a matter of minutes but the real challenge lay before me.  What we have in the present day Operating Room is the quintessential definition of the word “team”.   The individuals assembled on the orthopedic team in the OR today work together in a committed way, displaying a clear sense of camaraderie, and a shared sense of accountability and responsibility for the outcome.  The staff assembled for this case was comprised of competent individuals with a common goal to care for this man; however, we were unknown to each other, and the additional burden of this lack of familiarity further compounded the already tense situation.

Not only was I in an unfamiliar environment with unfamiliar staff, I had the additional challenge of unfamiliar equipment and instrumentation.  Although remarkably similar, the metal pieces and parts that I would use to reconstruct his shattered tibia were worryingly dissimilar as well because they vary greatly depending on the manufacturer.  Not surprisingly, the instrumentation and items available at St. Joseph’s were different than any I had used before.  This was yet one more star that fateful night that seemed not to be aligned in a positive path. 

After rifling through the sterile supply area, I assembled the items that would best help me reconstruct the contorted leg.  The best approach to this scenario was to use external fixation to rebuild and immobilize the bones, affording the broken bone the best opportunity to heal without residual damage.  The surgical application of an external fixation device is strikingly similar to the technology used by a child when constructing an erector set.  The popular childhood toy consists of metal beams, nuts, bolts, screws and other such mechanical parts that can be used by innovative and imaginative children to construct endless objects such as robots, mechanized cars, buildings, and other limitless creations of the mind.  Similarly, external fixation is a surgical technique used to immobilize bones by placing pins and screws into various locations along the fractured bone. They are then attached by bars, sprockets, clamps, and hinges to a main device or frame outside of the skin where it can be controlled and adjusted to attain proper anatomical alignment of the bone.  During the course of the next several hours, I used this “operative” erector set to reconstruct the bone. 

Never far from my mind was also the concern that he displayed signs of peroneal nerve injury.  The peroneal nerve is a portion of the sciatic nerve located near the knee.  It is responsible for controlling the muscles that move the foot and toes.  Especially worrisome is that damage to this nerve can result in foot drop and other long term problems that could plague him throughout life despite an effectively healed fracture.  Addressing this problem during the surgical procedure added another dimension of complexity.

The surgical procedure was successful.  The patient steadily improved, was discharged, and gradually resumed the life of a college student. I returned to the process of integrating myself into the Syracuse Community and my new medical practice.  He, his family, and I were all infused with an extreme sense of gratitude.  They, for the successful outcome and his promised favorable recovery; me, for the fact that my first surgical case at my new hospital was challenging, but extraordinarily rewarding.  All the time, never far from my mind during that fateful night, was the fact that my performance and the outcome for this young man would be the first impression that I would make on the patient, his family, staff at the hospital, and the community in which I hoped to spend the next forty years. 

Many long-lasting bonds were forged that night.  My initiation into the St. Joseph’s family was a fait accompli and a positive experience. More than twenty years later I remain close to the patient and his family.  In essence, we grew up together.  I have continued to care for him as needed, as well as for his parents and other extended family members.  I recently mentally returned to the events of that night when I received a call from this man.  He required medical care for a non-orthopedic ailment and contacted me to ask my advice and opinion on this matter.  How very remarkable that more than twenty years later, the connection between us remains strong.

This case left a lasting impression on me.  The true test in life doesn’t occur when all is going well and the next moment can be predicted and therefore planned.  The truest life test occurs when we are faced with unexpected challenges and are able to meet and rise above them, elevating us to achieve great things.  Orthopedic surgical challenges are a part of what every surgeon experiences.  The story lines differ and the characters differ, however, what we all have in common is that it is stories like this that weave the fabric of our lives.

Friday, February 4, 2011

Coming Sunday........

Dr. Seth Greenky reflects on his first day as an attending surgeon, the patient whose life he impacted, and how that experience ultimately influenced his own life and surgical practice.

Wednesday, February 2, 2011

Factors Affecting Results Follow Up

On Sunday, January 16th we posted a piece that focused on the correlation between surgical volume (for both the operative surgeon as well as the facility in which it is performed) and outcomes.  We cited a Journal of Bone and Joint Surgery publication supporting this perspective.  The New York Times ran a similar piece this weekend again highlighting that standpoint and referenced the same journal article.  Follow the attached link to read the article in its entirety: