Optimal Bone Saw Blade Design

[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.

Lumbar Spinal Fusion Procedures: The Last 100 years

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 an advocate of Orthopaedic List .com

Accepting the Risks in Medical Education and Medical Practice

by Douglas Dirschl, MD

In a March 17, 2009 article in the New York Times, Dr. Richard Friedman, a professor of psychiatry at Weill Cornell Medical College, discusses the nearly universal preference patients have for a seasoned physicians over residents or physicians just out of training.  The strong perception is that physicians learn from experience, implying that the “practice” of medicine is just that – a process of continual learning and improvement.

How does one learn in medicine? Clearly, one large component has been intensive exposure to medical practice within the supervision of residency training programs.  Dr. Friedman points out to us, however, that there may be an inherent conflict at the heart of medical training: “what may be best for making a skilled, independent-thinking doctor may not always be best for patient comfort or safety”. We want our young physicians to be competent, knowledgeable, and confident, yet we also have a responsibility (and increasing scrutiny from regulatory and legal agencies) in protecting patients from the medical errors that could result from a physician’s inexperience.

All residents, at some point, leave the relative security of training and go out on their own. Some experts are now questioning whether medical training programs are striking the right balance between education and training and patient safety to produce physicians who can function optimally. Dr. Friedman argues that restrictions imposed by resident duty hour limitations, decreasing amounts of resident autonomy due to concerns of patient safety, and regulatory groups mandating that some medical complications should never occur, have combined to create a generation of young physicians who lack confidence in their ability to make judgments about patient care. In the pursuit of patient safety, we now deliberately prevent residents from acting independently on their own judgment in situations where a patient poses a theoretical risk.

It is said that 90% of orthopaedic residents currently go on to do fellowship training after residency. Is this because orthopaedics has become so highly complex that 5 years is not sufficient time to master it all, is it that residents completing programs today have less self confidence in their own abilities than the generation of physicians before them, or is it that society expectations have increased and it now expects ‘perfection’ of every physician, no matter how experienced. The answer is probably “yes, yes, and yes”.

To date, there are no reliable national data that regulatory changes in resident work hours, patient safety initiatives, or ‘never events’ (for example, CMS has determined that no patient should have a DVT after an orthopaedic procedure, and won’t pay for it if a patient does), have had a significant impact on preventable medical error or patient mortality rates. There is a cost to the development of professional identity of young doctors, arguing that it is hard to feel confident and independent unless you are given ample opportunity to stand on your own — and risk making a mistake.

There is no doubt that all physicians in training – and those in practice as well – pose an inherent risk to patients.  We should do everything we can to minimize this risk but recognize that doing so will probably impair physicians’ self-confidence.  We may end up with a generation of physicians who, by virtue of the environment in which they have trained, are more hesitant, more uncertain, and less self-confident that the American public might like.

Click here to read the full text of Dr. Friedman’s article.

Dr. Douglas R. Dirschl is Frank C. Wilson Distinguished Professor and Chair of Orthopaedics at UNC School of Medicine. He also serves on the Own the BoneSteering Committee and chairs the Critical Issues Committee for the American Orthopaedic Association.

Politics 101 for Orthopods

by Alan S. Routman, MD

If you ever get the chance, stop and take a look around at the way you practice orthopaedic surgery these days.  Certainly we have much better tools, devices, and technology than any of us ever imagined when we began our training years ago.  Some of these have improved patient outcomes, and some maybe not, but that’s a discussion for another day.

I’m thinking more of the government intrusion, the ever growing wedge that is being driven between us and our patients, and is radically shifting the landscape of our day to day practice.  Some guys simply dodge the oncoming train, and become employees of hospitals and multi-specialty groups and depend on practice administrators to steer them through the maze of new and burgeoning regulation.  The rest of us, in private practice, solo, or small groups, have to wonder if we can actually keep up with all the new rules and continue to maintain our medical lives the way we would like it to be.  Personally, I’m a patient oriented guy and can’t stand the thought of looking at an EMR on a computer screen instead of looking my patient in the eye.

This all brings me to the fact that our profession as orthopaedic surgeons is really worth fighting for.  Our training and skills, and what we can deliver to people in the ER, the OR, and in the office is truly wonderful.  And most of the time it’s fun, except when the paperwork and the intrusions drag us down and take us away from our work.

Remarkably, these are all the reasons why I believe it is incumbent on us, as surgeons, to take our message about patient care to the people who make the decisions that control our profession.  Those people are the politicians, and they know little to nothing about the practice of medicine.  We have to teach them.

Politics is a necrotic component of our society that seems to be completely devoid of any real knowledge or expertise about which many of the laws are made that govern us.  In medicine, this is having disastrous consequences and requires our immediate attention.  If we cannot educate and influence the people making laws, then we will (soon) witness the demise of the practice of medicine as we know it.  It is happening now, and not only in medicine.

I submit that my time can be better spent doing other things, based on my training and experience as a surgeon.  Unfortunately, I cannot afford to be a spectator to the debacle that is occurring before my own eyes.  If we do not act as a profession to stop this trend, then we too are guilty of the same negligence as the politicians.

Political advocacy is distasteful for many physicians, but, the practice of medicine is like a form of freedom. It may not be appreciated until it’s gone.  I write this to encourage all of my colleagues to consider political activism as important as anything else that one can do in their professional lives.  Forces are in place that will make physicians mere tools in the coming medical-industrial triangle of insurers, hospitals, and pharmaceutical giants.  Historically, those guys know how to play politics, and we don’t, and guess who the politicians are listening to.

Even if political involvement is personally distasteful, all of us can participate by speaking the language of politics, i.e., money.  Even if you can’t develop personal relationships with your local elected officials, you can still be a player by becoming an active member of your state and federal orthopaedic PACs, and also helping out when one of your colleagues asks for a check for a medicine friendly candidate running for office.  Don’t just walk away when you have the opportunity to support other surgeons who are working hard to make a difference in your profession.  Think in terms of making a major commitment, just like our competitors do, in your political involvement.  Checks for candidates at $500 are baseline, and $1000 annual contributions to your AAOS PAC (think Stu Weinstein) should be as automatic as paying the mortgage.  If you sit on the med exec committee of your hospital, you can play a huge role by ensuring its participation in political fundraising using those available (and painless) staff dollars.

Percentage of participation by orthopaedic surgeons is increasing, but is still miniscule compared to attorneys, chiropractors, podiatrists, and the like.  We have everything to lose, and they have everything to gain by the changing political landscape.  Together we can preserve and protect our profession.  Get off your financial butt, and develop a passion for the rising tide of physician advocacy.  Together we can have the influence and power that will make a difference in the evolving healthcare debate.  We need you to be on the team and play this important role in the fight for our future.

Dr. Routman is an orthopaedic surgeon in Fort Lauderdale, FL.  He has been President of the Florida Orthopaedic Society and a member of the Board of Councilors of the American Academy of Orthopaedic Surgeons.  He is currently the Vice Chairman of the Broward County Health Facilities Authority Board, on the Board of Governors of the Florida Medical Association, and is the Vice Chairman of the Florida Medical Association Council on Legislation.

True Success

by Tom Morris

From Plato and Aristotle to the present day, the wisest people who have ever thought about challenge and achievement in our lives and work have left us bits and pieces of powerful advice for attaining true success in anything we do. I’ve put these ideas together in a simple framework of seven universal conditions. Let me lay them out briefly and then we’ll look at each. Whether you apply them in your practice, in your life, or teach them to your patients, they can be very helpful for focusing on what it takes to reach important goals.

The 7 Cs of Success

For the most deeply satisfying and sustainable forms of success, we need to bring into any challenge, opportunity, or relationship:

(1) A clear CONCEPTION of what we want, a vivid vision, a goal clearly imagined.

(2) A strong CONFIDENCE that we can attain that goal.

(3) A focused CONCENTRATION on what it takes to reach the goal.

(4) A stubborn CONSISTENCY in pursuing our vision.

(5) An emotional COMMITMENT to the importance of what we’re doing.

(6) A good CHARACTER to guide us and keep us on a proper course.

(7) A CAPACITY TO ENJOY the process along the way.

There are certainly other concepts often associated with success, but every other one is just a version or application of one of these in specific situations. The 7 Cs give us the most universal, logical, and comprehensive framework for success.

(1) A clear CONCEPTION of what we want, a vivid vision, a goal clearly imagined.

In any facet of our lives, we need to think through as clearly as possible what we want to accomplish. True success starts with an inner vision, however incomplete it might be. The world as we find it is just the raw material for what we can make it. We are meant to be artists with our energies and our lives. And the only way to do that well is to structure our actions around clear goals.

(2) A strong CONFIDENCE that we can attain the goal.

Inner attitude is a key to outer results. Philosopher William James learned from championship athletes that a proper confidence should be operative in all our lives. In any new enterprise, we need upfront faith in what we’re doing. Sometimes we may have to work hard to generate this attitude. But it’s worth the work it takes, because it raises our prospects for success. The best confidence arises out of competence and then augments it.  It’s of course no guarantee of success. But it is among the chief contributors to it.

(3) A focused CONCENTRATION on what it takes to reach the goal.

Big dreams just lead to big disappointments when people don’t learn how to chart their way forward. Success at anything challenging comes from planning your path and then putting that plan into action. Gestalt psychologists teach us that a new mental focus generates new perceptual abilities. Concentrating your thought and energy in a new direction, toward a clear goal, you begin to see things that you might have missed before, that relate to the goal you’ve set. This focus allows you to plan and act, and adjust along the way. Even a flawed plan can start you off and lead you to where you can discover a better one. A focused concentration of thought and action is key.

(4) A stubborn CONSISTENCY in pursuing our vision.

The word ‘consistency’ comes from two Greek roots, a verb meaning “to stand” and a particle meaning “together.” Consistency is all about standing together. Do my actions stand together with my words? Do my reactions and emotions stand together with my deepest beliefs and values? Do the people I work with stand together? This is what consistency is all about. It’s a matter of unifying your energy and efforts in a single direction. Inconsistency defuses power. Consistency moves us toward our goals.

(5) An emotional COMMITMENT to the importance of what we’re doing.

Passion is the core of extraordinary success. It’s a key to overcoming difficulties, seizing opportunities, and getting other people excited about your projects. Too much goal setting in the modern world has been an exercise of the intellect and not also of the heart. Philosophers appreciate the role of rationality in human life. But we know that it’s not just the head, but also the heart, that can guide us on to the tasks right for us, and keep us functioning at the peak of our abilities.

(6) A good CHARACTER to guide us and keep us on a proper course.

Character inspires trust. And trust is necessary for people to work together well. Good character is required for great collaboration. In a world in which innovative partnerships and collaborative synergies are increasingly important, the moral foundation for working well together matters more than ever before. And good character does a lot more than just provide for trust. It has an effect on each individual’s own freedom and insight. Bad character not only corrupts, it blinds. A person whose perspective has been deeply skewed by selfishness or mendacity cannot understand the world in as perceptive a way as someone whose sensibilities are ethically well formed. Good character makes sustainable success more likely.

(7) A CAPACITY TO ENJOY the process along the way.

The more you can enjoy the process of what you’re doing, the better the results tend to be. It’s easier to set creative goals. Confidence will come more naturally. Your concentration can seem effortless. Consistency will not be a battle. The emotional commitment will flow. And issues of character will not be as difficult to manage. A capacity to enjoy the process is entwined with every other facilitator of success in a great many ways.

****

These conditions of success are all deeply connected. They constitute a unified framework of tools with which we can work our way toward the most fulfilling forms of achievement. They will help us to make our proper mark in the world. They will move us in the direction of true success. And why should we ever settle for anything less?

Tom Morris is the author of such books as True Success, The Art of Achievement, If Aristotle Ran General Motors, and If Harry Potter Ran General Electric. He writes weekly for The Huffington Post and can be found philosophizing on Twitter as TomVMorris.  He can be reached at TomVMorris@aol.com or through the Morris Institute.

Dr. Morris was kind enough to guest author this article for OrthopaedicLIST.com.

The Prayer of a Surgeon Emeritus

by Howard H. Steel, MD

Lord, Thou knowest I am growing older.

Keep me from becoming talkative and possessed with the idea that I must express myself on every subject.

Release me from the craving to straighten out everyone’s affairs.

Keep me from the recital of endless detail.  Give me wings to get to the point.

Seal my lips when I am inclined to tell of my aches and pains.  They are increasing with the years, and my love to speak of them grows sweeter as time goes by.

Teach me the glorious lesson that occasionally I may be wrong.

Make me thoughtful but not nosy, helpful but not bossy.  With my vast store of wisdom and experience, it does seem a pity not to use it all, 

but Thou knowest, Lord, that I want a few friends at the end.

 [Published with permission from Dr. Steel.]

Howard Steel, MD is an icon in Orthopaedics and his inspiration goes beyond Orthopaedics.   Clinically he dedicated his career to children at Temple and the Shriners.  Educationally, he taught thousands of residents, medical students and junior faculty about surgery and life.  In 1970, he founded the Eastern Orthopaedic Association and was the Society President for the first two years.  He has hardly missed a meeting since.  Recognizing there is more to life than medicine, Dr. Steel donated funding (30+ years) for a “non-Orthopaedic” lectureship for many of the regional orthopaedic societies, the AOA and other orthopaedic entities.   Howard is funny, fun-loving and bigger than life.  

Comments about Dr. Steel by Judith F. Baumhauer, MD MPH, University of Rochester School of Medicine and Dentistry

It’s (More Than) OK to Do the Right Thing

by James D. Hundley, MD

            As a retired orthopaedic surgeon, I miss the hallway consultations where colleagues discuss cases while trying to determine the best course for our patients.  Fortunately I am still consulted from time to time and get to enjoy sharing ideas and opinions.

A few weeks ago I was called by a young surgeon who was perplexed by what would be best for his patient, an elderly, emaciated, osteoporotic woman with end-stage Parkinson’s Disease.  She had suffered a displaced, four-part fracture of her proximal humerus from a fall.  He had been taught that these need open reduction and internal fixation (ORIF) if the patient is to regain good function and felt obligated to offer that as a choice.  When so offered, she had stated that she did not want surgery but would think about it.  When he called me, he was dreading that she would call him in the next day or two saying she wished to proceed with ORIF.  How should he respond?

For me the answer was easy.  Treat her with a sling and swathe until the acute pain had subsided and then begin gentle range of motion exercises.  Sure, she would never regain function anywhere near normal but she could still use her elbow and hand to eat and for other similar activities.  Even better, she could bypass the possibility of anesthetic complications and surgical ones such as infection, blood loss, loss of fixation, nerve injury, and so on.

Being the one “in the trenches”, however, and having been taught that the proper treatment was operative, the decision-making for him was more stressful.  He felt that the right thing to do was non-surgical, but feared that that would not be acceptable morally and could put him at risk for a lawsuit.  That’s when I reassured him by saying, “It’s OK to do the right thing.”

I’ve always felt that decision-making is the most difficult part of orthopaedic surgery.  Sure, you must have a significant degree of core knowledge to understand the disorder and have an array of treatments at your disposal.  Probably the biggest decision is whether or not to operate and when if ever to do it.  If you don’t do surgery, how else would you best treat the patient?  If you do surgery, what is the best procedure?  If you run into surprises during surgery, what do you do then?  In every instance, the best decision is what is best for that particular patient at that particular time.  Sometimes, “doing the right thing” requires you to swim against the tide of current opinion and/or what you learned during your training years.  Over time, however, with personal experience and through seeing a variety of perfectly acceptable ways that our colleagues manage similar problems, we can and must learn to trust our judgment as to what is best for our patients.  Thus, no matter which way the fads are pointing at the time, when you include the patient’s wishes and do the right thing, it is always OK.  In fact, it’s more than OK.  It’s what should be done.

Epilogue:  In case you’re wondering, the patient remained steadfast and decided to not have surgery.  Had she requested it, I don’t know what he would have done, but I’ll bet he would have declined to do it.  Thus, although the whole conversation was moot it was interesting and will hopefully help him the next time he is conflicted by what he thinks he should do vs. what he thinks others would have him do.

Dr. Hundley is a retired orthopaedic surgeon with forty years of experience.  He is also a founder and the president of OrthopaedicLIST.com, a free and open-access directory of orthopaedic products and services that was established in 2003 and currently lists over 10,000 products and services for orthopaedic surgeons and related professionals.

Book Review: barebones. A Surgeons’s Tale. by Augusto Sarmiento, MD

 by James D. Hundley, MD

barebones is the inspirational story of a bright, ambitious young man imbued with an iron will and an unwavering inspiration to benefit society through Medicine in general and Orthopaedic Surgery in specific.  This review is not intended to be comprehensive nor do I expect book reports to become a routine of the OrthopaedicLIST.com blog.  It’s simply that Dr. Sarmiento’s life history and his views are so interesting and compelling that I wish every orthopaedic surgeon and resident in training, indeed every physician in the United States, would read it.  As for immigrant physicians, Dr. Sarmiento’s story could well become their Bibles.

The story is well written and describes Dr. Sarmiento’s life and his family struggles when he was a young man through his medical training in Colombia to his orthopaedic residency in the U.S. as an immigrant who could barely speak English to his rise to prominence as an innovator, researcher, academician, and chair of three departments of orthopaedic surgery (two in the U.S. and one in Scotland).  Being elected President of the American Academy of Orthopaedic Surgeons, the largest and among the most prestigious of orthopaedic surgeon associations is evidence of the esteem by which he was held by his fellow surgeons.

As a resident in orthopaedic surgery in the late 60’s and early 70’s I well remember his innovative, dynamic treatment of long bone fractures as it rose to prominence.  I was fortunate to have received my training in a conservative program where the closed treatment of fractures was the first consideration and ORIF was simply one of the choices.  Moving from a long-leg cast to a PTB one for tibia fractures was a huge advance for our patients.

Dr. Sarmiento’s interest and expertise in the treatment of adult hip problems was not as well known, but he contributed significantly to that field as well.

The most compelling message from the book relates to Dr. Sarmiento’s observations of the changes in focus by some orthopaedic surgeons during his career.  Dr. Sarmiento was steadfast in putting the interests of his patients first and foremost while having to fight bureaucrats in hospitals and academic centers as well as politicians and observing and feeling the effects of powerful, fellow orthopaedic surgeons who put self interest before that of their patients and medical centers.

He also documents the efforts and effects of the powerful orthopaedic companies whose “good business” practices were not necessarily “good for patient” practices and believes that these companies have almost taken over the postgraduate education of orthopaedic surgeons.  He believes that the spiraling cost of medical care is one of the unfortunate side effects of that particular shift in source and surgeons practice “cosmetic bone surgery”, surgery that is not indicated for human function.

My only criticism of the book is that Dr. Sarmiento tends to paint our profession with a broad brush of negativity and, like most of us, is concerned that our medical profession will not continue to attract the best and brightest to become physicians.  Fortunately, the numbers and academic qualifications for those applying to medical schools have never been higher.  Hopefully those people will also make good doctors, a concern also addressed by Dr. Sarmiento.

I wish that I could require every orthopaedic surgeon, resident and practitioner, to read Dr. Sarmiento’s barebones.  As that is not within my power, I can only hope that this brief review will entice more to do so.

barebones.  A Surgeon’s Tale by Augusto Sarmiento, MD, Prometheus Books, 59 John Glenn Drive, Amherst, New York 14228-2197, www.prometheusbooks.com, Published 2003, 379 pages

Dr. Hundley is a retired orthopaedic surgeon living in Wilmington, NC and president of OrthopaedicLIST.com.

Own The Bone

by Douglas Dirschl, MD

In the fall of 2008, I wrote an article for OrthopaedicList.com about the high prevalence of fragility fractures in the United States, how only 20% of Americans sustaining a fragility fracture received the appropriate evaluation and treatment of their underlying osteoporosis, and how the American Orthopaedic Association had successfully piloted a program called “Own the Bone” to help improve patient care and change physician behaviors related to this issue. Today I write to communicate to you that the AOA’s Own the Bone™ program has been launched nationally and is currently accepting enrollment by hospitals, physicians, and/or communities of practitioners. I encourage you to read on and to visit www.ownthebone.org for additional information.

Own the Bone™ is an evidence-based quality improvement program for patients with fragility fractures. The program endeavors to bring together hospitals, providers, patients and communities around improving the lives of patients with osteoporosis and fragility fractures. Own the Bone™ is designed to prevent future fractures in patients who have sustained fragility fractures by increasing the application of current evidence-based guidelines set forth in the National Osteoporosis Foundation Clinician’s Guide to the Prevention and Treatment of Osteoporosis and highlighted in the 2004 Surgeon General’s Report on Bone Health and Osteoporosis.

The goals of Own the Bone™ are to assist clinicians in identifying, evaluating, diagnosing, and treating patients with poor bone health after a fracture and improving awareness of the fracture risk. In this program, adherence to evidence-based treatment guidelines is measured. Ultimately, Own the Bone™ endeavors to reduce the risk of secondary fragility fractures in participating patients.

Participation in Own the Bone™ makes it easy for physicians and hospitals to do the right thing for these patients. The program facilitates patient education efforts by providing a downloadable library of patient education materials and promotes guideline-based care through the use of computerized reminders based on patient characteristics. The easy-to-use web interface streamlines submission of data and retrieval of educational materials, as well as completion of the easy-to-use electronic case report form. Data submitted to the Own the Bone™ program is used to develop confidential benchmarking reports for sites to evaluate progress and improve systems of care based on evidence-based guidelines. These reports also allow sites to compare their results against the aggregate results of other program participants.

Participating in Own the Bone™ requires the following:

  1. Enrolling as a site in the program;
  2. Identifying patients > 50 years of age presenting with a fragility fracture;
  3. Screening, educating, and treating patients as appropriate;
  4. Entering patient information into web-based quality improvement registry;
  5. Following up with patients after 60-90 days via a letter or phone call (this is a recommended, not mandatory, step).

The Own the Bone™ registry constitutes a Limited Data Set under HIPAA requirements. The only elements of potentially identifiable Protected Health Information included are date elements and patient ages, so the program may not require full IRB approval at many institutions.

Subscribers are provided with many benefits. Some of the benefits include:

  • Comprehensive start-up materials to help simplify the implementation of the program (available both in hard copy and online through a secure, subscriber-only section);
  • Access to a national Web-based registry, with reporting and benchmarking capabilities;
  • Best practice library;
  • Patient education tools;
  • Physician education tools;
  • System generated Patient and Physician letters documenting the patient’s risk factors;
  • Public relations tools (press release/communication templates and access to a “participating member”);
  • Web-based training;
  • Ongoing best-practice sharing;
  • Electronic newsletters.

The Own the Bone program has been designed to enable a healthcare community – hospitals, orthopaedists, and other physicians and providers – to improve the care of patients in their own backyard. The program can make it very easy to do the right thing for these patients, improve their lives, and reduce their risk of subsequent fractures. I encourage you to refer your hospital administrators, practice partners, and other physicians in your community to the Own the Bone™ website. Additionally, please don’t hesitate to call on me; I will assist you any way I can in convincing your hospital and the physicians in your community that ‘owning the bone’ is in their best interest and that of their patients.

Also, please check out the informational webinar available on the “provider” link at the Own the Bone™ website.

Dr. Douglas R. Dirschl is Frank C. Wilson Distinguished Professor and Chair of Orthopaedics at UNC School of Medicine. He also serves on the Own the Bone Steering Committee and chairs the Critical Issues Committee for the American Orthopaedic Association.

Osteoporosis

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.