Shoulder Injuries in Athletes

Bradley S. Raphael M.D.

RSM Medical Associates

          

As spring sports start up (lacrosse, baseball, tennis) so to can shoulder pain.  Shoulder injuries are common in overhead athletes (swimming, tennis, baseball, football), but can also occur in overhead workers.  This is especially true with heavy laborers or jobs which require repetitive overhead activities at work.

Different shoulder problems from overuse:

                -Impingement

   -Rotator cuff tears

                -Rotator cuff tendinitis

                -Labral tears

                -Instability/dislocation

               

Anatomy:

-The shoulder is essentially a ball in socket with less restriction than any other joint in the body.  This allows the shoulder to be the most mobile joint in the body.

                -Rotator cuff is a series of 4 muscles that center the ball on socket during shoulder motion, maximizing the efficiency of shoulder movement.  These can be inflamed with repetitive motion and can make overhead activity painful.

                -The rotator cuff can also become inflamed as it rubs under the color bone and shoulder blade (often described as a “bone spur”)

                -The labrum is made of a thick tissue that rings the shoulder socket and is susceptible to injury with trauma to the shoulder joint. When a patient sustains a shoulder injury, it is possible for the labrum to tear. Some symptoms are an achy sensation to the shoulder joint, catching of the shoulder with movement and pain with specific activities

Treatment:

                -These injuries are often treated with physical therapy, strengthening, stretching, (especially baseball players and other overhead athletes)

                -It’s important to do appropriate warm up before long pitching outings, lacrosse games, tennis matches and overhead work activity in order to prevent injuries.

                -If physical therapy fails, may need an injection to help decrease pain (steroid).

                - These injuries usually respond to conservative measures, but sometimes it can become refractory and may need arthroscopic procedure to clean out bursitis, remove bone spurs or repair the tendons or labrum.

               

Prevention:

                -Important to follow little league pitching guidelines at young age (littleleague.org)

                -Pre-game, pre-work, and pre-activity stretching

                -Hip and core strengthening to alleviate stress on shoulder with your local therapist or athletic trainer.

                -See your doctor as soon as you start having soreness that doesn’t go right away, because it could be the sign of something more serious

Bradley S. Raphael M.D. completed his sports medicine training in Los Angeles at the Kerlan Jobe Orthopedic Clinic and is in practice at RSM Medical Associates where he specializes in Shoulder and Knee problems. He is also a team physician for Syracuse University Athletics.  For appointments or questions: 315-701-4024 or on the web at raphaelmd.com

Rotator Cuff Tears

By Ryan Smart, MD

Syracuse Orthopedic Specialists

Intro

Rotator cuff tears are among the most commonly encountered disorders of the shoulder.  They can be debilitating and difficult to treat.  Chronic rotator cuff tears are common and with the aging population the incidence of new tears continues to rise.  More than 50% of individuals older than 60 years have at least a partial rotator cuff tear and full thickness tears are found in almost half of individuals older than 80 years. (1)  Approximately two-thirds of all rotator cuff tears in the general population are asymptomatic and factors found to be associated with symptoms when one has a rotator cuff tear are a positive impingement sign, weakness in external rotation, and presence of a tear in the dominant arm. (2)  Procedures done to treat rotator cuff disease are among the most common of all orthopaedic surgeries.

Anatomy

The glenohumeral joint has very little bony support.  The rotator cuff, which is made up of four muscles (subscapularis, supraspinatus, infraspinatus, and teres minor), plays a major role in both the mobility and stability of the shoulder.  Of these two roles, stability appears to be the larger function.  To maintain a ball-and-socket articulation during motion, the humeral head is compressed into the glenoid socket by the rotator cuff.  Without such compression, the humeral head can undergo excessive translation within the socket which disrupts shoulder kinematics.  EMG studies have shown that the rotator cuff muscles fire prior to and then concurrently with the deltoid and pectoralis major muscles.(3)  This preceding and concurrent activation of the rotator cuff muscles maintains the shoulder joint for dynamic stability during larger muscle contractions.

History

Pain is the most frequent complaint.  It can at times radiate down the arm to the level of the elbow.  Many patients will complain of nighttime pain.  Typically, the pain will be worse with certain motions such a forward elevation or abduction.  As the tear progresses, weakness will become a more prevalent symptom.  Rotator cuff pain does not typically radiate down the arm to the level of the wrist or hand.  If such symptoms are present one should suspect the cervical spine as the pain generator.  A history of a trauma or fall will sometimes be present but many times patients cannot recall a specific inciting event.

Physical Exam

A thorough physical exam significantly aids in the diagnosis and management of rotator cuff tears.  A complete shoulder exam should be performed starting with inspection and palpation.  Range of motion is then assessed both passively and actively.  If both passive and active motion is limited one should consider an alternative diagnosis such as adhesive capsulitis (ie frozen shoulder).  Patients with rotator cuff pathology will typically have mid-arc pain.  A positive Neer and Hawkins maneuver is common.  Strength testing is performed for each rotator cuff muscle.  The empty can and drop arm maneuvers test the supraspinatus.  The lift-off, belly press and bear hug all test the subscapularis and external rotation strength tests the infraspinatus and teres minor.  The combination of a positive drop-arm sign, painful arc sign, and infraspinatus muscle strength test was most predictive for full thickness rotator cuff tears.(4)

Treatment

Conservative

Nonsurgical management is typically the first line of treatment for most rotator cuff pathology.  The natural history of rotator cuff tears is thought to be that of tear progression. (5)  It is believed that tear size progression is a factor in the development of symptoms.  Physical therapy and shoulder rehabilitation should focus on restoration of motion, flexibility and strength. (6)  Nonsurgical management may also include pain medication and anti-inflammatory drugs and subacromial cortisone injections.  Although injections are common a recent systematic review suggests that long-term benefits are limited. (7)  Multiple cortisone injection should be avoided in patients who may be best served with surgical intervention.  Successful non-operative management has been correlated with symptom duration of less than 3 months.  Factors that have been found to predict failure of conservative treatment are: 1) full-thickness tear greater than 1cm x 1cm, symptoms present for more than 1 year, and functional impairment and weakness. (8)  Nonsurgical treatment is often attempted for a minimum of 6 to 12 weeks before surgery is considered.

                Surgical

When patients fail conservative treatment surgery is usually indicated.  Tears can be repaired either arthroscopically or by open means.  The clinical results reported with arthroscopic repairs are equivalent to those reported for both open and mini-open. (9,10)  However, the deltoid muscle is undisturbed with arthroscopic repairs thus making it the favored approach by many.  The goal of surgery is to anatomically repair the rotator cuff securely to bone with as little tension as possible.   Reported healing rates, based on ultrasound and MRI, range from 91% in small tears to 10% in massive tears. (11)  With larger tears, the best clinical results are achieved in patients who experience tendon healing postoperatively. (12)

Rehab

The ideal rehabilitation program allows for tendon to bone healing and prevents stiffness.  Most agree the best clinical results occur when the rotator cuff heals to bone in its entirety.  Since the rotator cuff heals very slowly (~5% per week) most have adopted fairly conservative rehab protocols limiting motion the first 6 weeks.

Dr. L. Ryan Smart specializes in sports medicine, arthroscopic surgery, and shoulder surgery.  He completed his fellowship in sports medicine at the New England Baptist Hospital in Boston, MA and completed his orthopaedic surgery residency at Yale in New Haven, CT.   After completing his undergraduate studies at Cornell University, he went on to the University of Michigan for medical school.  He is the team physician for the Christian Brothers Academy football team, Cornell Men’s Ice Hockey, Syracuse Silver Nights soccer club and Fayetteville-Manlius High School. He played 4 years of varsity ice hockey at Cornell and was drafted by the New Jersey Devils in the 1994 NHL entry draft.  His professional memberships include Arthroscopy Association of North America and the American Orthopaedic Society for Sports Medicine.

 

Anterior Cruciate Ligament (ACL) Injuries:  What You Need To Know

 By Todd C. Battaglia, MD, MS

Tears of the anterior cruciate ligament (ACL) are among the most common knee injuries, particularly in high demand sports like soccer, football, and basketball. In fact, more than 200,000 ACL injuries occur each year in the United States alone and affect individuals of all levels, from recreational athletes to professionals. In recent years, numerous well-known athletes, including Tom Brady, Ricky Rubio, and Tiger Woods, have suffered well-publicized ACL tears.

THE BASICS

Ligaments are strong bands of tissue that connect one bone to another. The ACL, one of two ligaments that cross in the middle of the knee, connects your thighbone (femur) to your shinbone (tibia) and helps stabilize your knee joint. It prevents the tibia from sliding forward in front of the femur, as well as provides rotational stability to the knee. The ACL can withstand approximately 500 lbs. of pressure, but only a 25% stretch, before failing.

Injured ligaments are considered "sprains" and are graded on a severity scale from a mild stretch (Grade 1) to a complete tear (Grade 3). Partial tears of the ACL are relatively rare; most ACL injuries are complete or near-complete tears. About half of all injuries to the ACL also involve damage to other structures in the knee, such as articular (joint) cartilage, meniscus, or other ligaments. Nearly 80% of ACL tears are the result of non-contact injury (cutting, jumping, sudden stops); this is much more common than direct contact or collision ACL tears. Female athletes have a much higher incidence of ACL injury than male athletes (between 2-7 times more common). It is thought that this is due to differences in leg alignment, muscular strength, and neuromuscular control. It is also believed that hormone differences play a role, as estrogen may weaken ligaments.

SYMPTOMS

When you injure your ACL, you may hear a "popping" noise and you may feel your knee give out from under you. Most ACL tears are associated with moderate to severe pain. The knee will usually swell (often severe) within 4-8 hours of injury. Other symptoms may include loss of motion, tenderness along the joint line, and discomfort while walking.

The pain and disability associated with an ACL injury usually prompts most people to seek medical attention. Continued athletic activity on a knee with a torn or malfunctioning ACL can have devastating consequences, resulting in severe cartilage damage and increased risks of arthritis.

DIAGNOSIS

Diagnosis of an ACL tear primarily relies on the physical examination performed by your doctor. Through movement and manipulation of your knee, the physician can usually diagnose an ACL tear without use of any special tests. X-rays may be taken to rule out a bone fracture. But X-rays cannot visualize soft tissues such as ligaments and tendons, so an MRI, which can, is often used to confirm the diagnosis and to evaluate for torn cartilage or other injuries often associated with ACL tears.

TREATMENT

Initially, treatment for an ACL injury aims to reduce pain and swelling, regain normal knee movement, and strengthen the muscles around your knee. Ultimate treatment, however, will depend on several factors, such as the severity of the injury, presence of associated injuries, and most importantly, the patient’s individual needs. If the overall stability of the knee is intact, your doctor may recommend simple, non-surgical options. This might include physical therapy to strengthen the leg or use of a brace during certain activities.

A completely torn ACL will not heal without surgery, and the lack of a functioning ACL greatly increases the risk of other knee injuries, such as a torn meniscus, so sports with cutting and twisting motions are strongly discouraged. For younger patients and those who frequently participate in such sports, surgery will most likely be required to safely return to those activities. But non-surgical treatment may be effective for patients who are elderly or have a very low activity level.

If surgery is chosen, a torn ACL cannot simply be sewn back together. During surgery the ACL is not repaired; instead, it is reconstructed - your doctor will replace your torn ligament with a tissue graft. This graft acts as a scaffold on which a new ligament will grow.

Grafts can be obtained from several sources. Some are taken from the patient’s own body (autografts) and include the hamstring tendons or patellar (kneecap) ligament.  Alternatively, various cadaver grafts (allografts) can be used. There are different advantages and disadvantages with each graft option; factors to be considered are graft strength, healing time, re-tear rates, and infection risks. Your surgeon should discuss graft choices thoroughly with you prior to surgery to help determine which option is best for you.

Nearly all ACL surgeries today are performed with an arthroscopic camera, using small, minimally invasive incisions. Although arthroscopic reconstruction has been performed for more than two decades, over the last five years, ACL surgery has undergone a major revolution. New strategies and techniques, particularly with regard to placement sites of the new graft, have shifted dramatically. We have learned, unfortunately, that the techniques used 10 or 20 years ago did not do a good job of placing the new graft in the same location as the patient’s original ACL. Our newer techniques have resulted in greatly increased stability, and although not yet proven, we suspect will also reduce the likelihood of subsequent arthritis in these knees.

After surgery, crutches and a brace are typically used for a period of time, usually 2-6 weeks.  The rehabilitation process is a very important part of the surgery. There is a long and rigorous course of physical therapy required, first focusing on returning motion to the joint and surrounding muscles. This is followed by a strengthening program designed to protect the new ligament. This strengthening gradually increases the stress across the ligament. The final phase of rehabilitation is aimed at a functional return tailored for the athlete's sport. Because the biologic healing and re-growth process take time, it may be 6 months or longer before an athlete can return to sports after surgery. A surgeon who promises a faster return to sports is doing the patient no favors – early return to sport before appropriate healing has occurred is associated with much higher rates of re-injury to the ACL.

The most common risks of ACL surgery include infection, persistent instability or pain, and stiffness. The good news is that better than 90% of patients have no complications with ACL surgery. Most patients are able to return to their previous level of athletic activity; however, for very high-level athletes, this is not always the case. For instance, only 50-60% of professional football players return to the NFL after ACL surgery.

PREVENTION

Some studies have shown that rates of ACL injury can be reduced anywhere from 20% to 80% by engaging in specific training designed to enhance balance, proper movement patterns, and muscle strength. Not all physicians agree with this, however, and other studies show much less, if any, benefit from these “ACL prevention programs.” In addition, although many sports medicine doctors frequently prescribe knee braces, there is no scientific evidence to date that braces significantly prevent ACL tears.

Dr. Battaglia is a board-certified, fellowship-trained orthopedic surgeon at Syracuse Orthopedic Specialists, PC. He specializes in sports medicine and reconstructive surgery of the shoulder and knee, and has a particular interest in ACL injuries and revision surgery for failed ACL repairs.

Operation Walk Syracuse Nepal Closes as Operation Walk USA Kicks Off This Weekend

During the long return trip to Syracuse, Dr. Seth Greenky penned his thoughts about our just completed surgical mission at Nepal Medical College:

How do you describe a life changing experience to someone else and capture the spirit of the event- especially when one lacks the skills of writing. A group of ragtag "Syracusians" with a sense of adventure and a desire to tackle major hurdles, altruistic to the extreme, traveling literally to the other side of the world to help people. A dream that started with casual conversation and morphed into reality mostly by extremely hard work and some luck.  Sometimes the stars just come together and magic occurs.

I feel like we were the Olympic hockey team that tackled a task and succeeded beyond all of our expectations.

The group was not a team that regularly worked together. We were composed of individuals who come from different hospitals, different outpatient facilities, different cities, different religions, different motivations, different ages, different stages in life, and I could go on and on. All received nothing but the potential satisfaction of doing something special for someone else. No one got paid, no one got "comped" time off and there was a minimal hierarchy at best.

This was our inaugural visit sort of a "try out" for the Operation walk team so to speak. We were being judged by the Operation walk LA division- the originators and supervisors of the 13 sites. Four rooms, the lead organizer, three PA's, six surgeons (thank God because I was sick as a dog for the first two days),two anesthesiologists, two nurse anesthetists, circulating nurses, OR techs, floor nurses, Physical Therapists,  an instrument tech, a representative from the company that donated all the prosthesis, a Mr. fix it/ engineer, a supply coordinator, our translator and cultural guide, and I probably forgot someone.

Let me just sum up how we did- we kicked ass! Not one single complaint the entire time; despite heat, exhaustion, GI issues, communication issues and more. We had incredible mentoring from our LA counterparts, but we were seamless in our ability to run with guidance and soon mesh with them and ourselves. Compliments from our LA mentors, our Nepalese friends (physicians, nurses, housekeeping staff, etc) were over the top.

I think I can say without reservation one of the top experiences of my life and of all those of us who participated. There is no substitute for the feeling you get from a selfless act of good.

I am beyond proud of our team, and feel that the hand of God was with all of us. The faces of the patients and their families is ingrained in all of our minds. There were no stars, there was essentially one unit that won the ultimate victory. Hurrah for all of us.

We will be doing this again, and again, and again.....

Seth Greenky

Operation Walk Syracuse: Nepal 2011

His name was Pramod Kumar Yadov. As we sat in the post screening clinic conference debating the risks and benefits for each patient before proceeding with surgical procedures, my mind flashed back to a day shortly after we arrived in Nepal.  I walked the grounds with Dr. Saswat, the orthopedic resident assigned as our Operation Walk liaison. He pointed to a distant sight. Awkwardly making his way across the pavement, steadied by a set of crutches, was a young man of approximately twenty five.  Saswat explained to me that he was a candidate for the Op Walk camp and had travelled from afar in hopes of undergoing bilateral hip replacements.

His hips were fused and he suffered from ankylosing spondylitis--a long term disease that causes inflammation of the joints between the spinal bones and the joints between the spine and pelvis. It eventually causes the bones to join together and mobility becomes progressively compromised, often to the point of complete incapacity.  His mobility had steadily diminished over the years and was now at the point that he was unable to independently care for himself.

The team debated his case and discussed the potential for surgical success.  From a medical standpoint, anesthesia would be a challenge. A successful spinal anesthesia modality would likely not be successful due to the anatomical challenges posed by his spine and rib cage. Although general anesthesia was a possibility, the anesthesia team lacked the critical equipment that might be necessary to safely manage the airway of a patient with major neck and spine abnormalities.  After all, general anesthesia was not in our plan for any of the patients as a primary anesthesia route.  From an orthopedic surgical standpoint, the procedures were not elementary, but certainly manageable.  Orthopedic score-2 and anesthesia/medicine score-3. Discussion engaging everyone in the room ensued relative to the potential for success and a positive outcome.

After what seemed like an eternity, the team rendered its decision. It was neither wise nor prudent to proceed with these procedures.  The inability to manage him from an anesthesia standpoint posed a serious threat and could possibly even result in his death.  The team had made its decision and that would then be explained to the patient. Disappointment hung heavily in the room, but the correct and safe decision had been made; or was it?

From the front of the room I heard the quiet and calm voice of the LA surgeon who accompanied us on the trip.  His presence on our orientation trip was intended to provide guidance and a means for an experienced resource to our novice team. He acknowledged that our assessment was completely accurate and the risks associated with proceeding with the procedures were high. He continued to engage us. Left untreated, this young man would be doomed to the effects of advancing disease with no way to mitigate the damage and destruction that would be left in it's path.  It wasn't a matter of "if" he would become completely immobile, but "when"? He challenged us.  Should the patient not be given the opportunity to make the decision if the benefits outweighed the risks for these procedures?  Should he not at least have that modicum of control over his own future and destiny?  And with that, the momentum changed.  Enthusiasm mounted.  The dialogue shifted to "how" this could be accomplished rather than "if" it could be accomplished.  

Surgery day two dawned with a sense of accomplishment from our initial operative day, and eager enthusiasm to launch into the series of more complex patients that this day promised to bring. The team was buoyed by increasing confidence and the comfortable camaraderie that had begun to develop and solidify.  Pramod had not only accepted the risks associated with his procedure, he desired to get in the OR as quickly as possible. His smile was ear to ear. There was no turning back for him. The day flew by quickly for us, but for him it was an eternity until his OR time arrived.  We had agreed he should be the last case of the day so that additional team members would be available, as well as limitless surgical time. He finally arrived in the OR.  That same dazzling smile greeted the team as the anesthesiologist worked his magic and by some miracle (or exceptional skill), the spinal slipped into place signaling the start of the surgical procedure.

The right hip replacement was completed, hemodynamic stability confirmed, and the anesthesiologist gave the green light to reposition the patient to the other side to commence the left side hip replacement. Everyone was excited about the realization that the second procedure could be initiated and therefore, the true therapeutic effects of the bilateral procedure could be achieved. We carefully began the transition to reposition the patient for the second procedure. This involved a brief stop in the supine (back laying) position prior to propping the patient up on the opposite side.   Much to our surprise and delight, Pramod lifted his head, steepled his hands in the traditional Nepalese manner, and with his broad smile intact, greeted us with "Namaste" as we turned him onto his back.  He deeply touched the hearts of all present in the room.  I recalled how close we were to denying him this life altering surgery and silently thanked the surgeon for nudging us forward appropriately.

Before long the surgery was finished and he was in the recovery room having received two new hips.  He was overwhelmed with emotion and joy. He gripped Dr Saswat's hand and searched his eyes for an answer to the question on the tip of his tongue.  "I marry now?" he exclaimed.  As Saswat answered in the affirmative, the grin broadened and was this time accompanied by dark eyes sparkling with hope for the future.  

Early the next morning family, friends, and a group of team members crowded around him as he ventured into the hallway taking his first steps. Filled with exuberance and free from pain, he cruised the hallway, physical therapist at his side.  Pramod became an inspiration to others (patients, family, and the Operation Walk team) for the remainder of trip. He touched the hearts of us all and impacted us in a manner that will not soon be forgotten.

We were drawn to him and nourished by the inspiration, hopes, and dreams that he symbolized.  I visited him several times each day and never found him to be without that wide grin and unflappable demeanor.  As our Operation Walk camp drew to a close, we assembled for the traditional team-patient photograph.  He spotted me across the room and motioned to me.  He patted the bed next to him and I sat.  I remained seated near him for a few moments, both of us silent but aware of the powerful exchange that was in process.  Before I realized what was happening, he had draped a vibrantly colored scarf around my neck and shoulders, pressed his palms together and with the smile that was now so familiar to me, nodded his head and exclaimed "Very Happy".  Operation Walk Nepal a life altering experience for us?  Perhaps.  A life altering experience and a promise for a future for Pramod?  Without a doubt. We depart Nepal content in the recognition that we made the right decision to proceed with his surgery.  Sometimes the message present in your heart must overrule the logic of your head.  

Kim Murray
11-18-11

Operation Walk Syracuse Kicks Off First Annual Mission

A group of patients in Nepal will receive joint replacement and rehabiliation in early November thanks to Operation Walk Syracuse, led by Co-Executive Directors Dr. Brett Greenky and Dr. Seth Greenky.

As the date for departure inches closer, our excitement mounts.  Months and months of preparation have come together and next week we will embark on the journey to the other side of the world.  We enthusiastically look forward to working with the physicians at Nepal Medical College have have more than 60 patients waiting to receive our services.

Our team of 36 volunteers comprised of surgeons, anesthesia providers, nurses, surgical technologists, physical therapists, and other team members are amazing.  We can't thank them enough for assisting us to make this mission trip a reality.  We will be joined by 12 members from Operation Walk LA who will provide guidance to us in our inaugural mission experience. 

In Kathmandu, the country's capital, many individuals cannot provide for their families due to the disabling physical limitations of degenerative arthritis.  Others cannot walk around their homes because they lack basic mobility equipment such as canes and walkers.

Our supplies (approximately 40,000 pounds of cargo) were shipped at the end of September.  We eagerly await confirmation of its arrival so that we can begin our travel next week with the confidence that all will be ready and waiting when we arrive.  We are all eager to begin working to restore the quality of life for many new people in Kathmandu, as well as to provide follow up care for patients from previous missions.

The group leaves November 8th.  Read daily updates and view photographs from the mission on the Operation Walk Blog at http://operationwalksyracuse.blogspot.com/. Posts will occur daily beginning on Tuesday, November 8th.

Fiscal Responsibility in Orthopedics

October not only introduces the expected autumnal change in climate resulting in cooler temperatures, shorter periods of daylight, and vibrant color changes to foliage, it also signals the start of the 2012 budgeting season for the orthopedic department.

As part of our "formalized" orthopedic service line at St. Joseph's Hospital, we are fortunate that this process for us has evolved to be a true partnership with the hospital, and a genuine multidisciplinary team effort which involves the physicians, nurses, physical therapy, and many other clinical support personnel. 

Gone are the days where the hospital holds sole decision-making authority when it comes to projecting operational costs (those recurring on a regular basis), and capital costs (purchase of equipment).  The difference between these two types of expenditures can easily be correlated to running or managing the finances of a household.  Operating costs associated with household management include the groceries purchased on a regular basis, as well as the payment of monthly utility bills.  In orthopedics, operational costs include the supplies and implants used during surgical procedures.  Capital costs associated with a household include the replacement of appliances that are at the end of their life (refrigerators, washers/dryers, snowblowers) or items that are new purchases (an entertainment center or furniture). In orthopedics, capital items include equipment that needs to be replaced such as drills, instruments, surgical tables, or specially designed hospital beds or chairs, as well as new technology-type items that keep our program up-to-date and able to deliver the highest quality patient care.

As physician leaders of this service, we take this responsibility very seriously. Escalating health care costs, specifically the rising cost of medical supplies and devices, are the responsibility of everyone to keep controlled. We work exhaustively with the Orthopedic Service Line Administrator to accomplish these very lofty goals.  

To accomplish this challenging task, we, along with the service line administrator, have hardwired specific processes into our service line management:

**Monthly product standardization meetings to explore new and alternative products that have the potential to improve quality while reducing costs

**Supply and implant control--no vendors, surgeons, or staff bring new items into the OR without prior committee review and approval

**Periodic implant re-bidding process for hip and knee components to ensure that costs remain controlled

**Scheduled replacement of equipment only when warranted and at end of life

**Review of all newly available orthopedic technology and planned addition if it makes sense from a quality and patient care standpoint as opposed to a passing fad

We have had significant positive results in controlling costs with this approach.  Our successful management of the orthopedic service line supplies and implants garnered recent national attention.  Our process was recently presented at the Managing Today's OR Suite Conference in Chicago.  A follow up article relative to this topic will be published in their national journal later this year.

Rest assured that we manage the hospital's precious resources for orthopedics in a fiscally responsible manner to ensure that the highest quality care is provided at the lowest cost. The effort in this regard is never considered finished and continues on an ongoing basis.  Our goal is to strengthen the orthopedics program at the hospital both today as well as into the future.