Physicians' Roundtable - Orthopedics
In this Physicians’ Roundtable, Eisenhower physicians discuss their orthopedic specialties, common orthopedic injuries, treatments, prevention, and vision for the future against the backdrop of their newly expanded facility. Our panel of experts includes Board Certified Orthopedic Surgeons Matthew Diltz, MD, Stephen O’Connell, MD, and David Tahernia, MD. Justin Thomas, MD, Board Certified in Pulmonary Disease, Interventional Pulmonary Medicine, Internal Medicine and Critical Care Medicine, moderated the discussion.
Dr. Thomas: As a spine surgeon, Dr. Tahernia, what are the primary reasons patients typically come to see you?
Dr. Tahernia: Patients generally see me if they have back or neck pain, leg pain or arm pain. Usually, other forms of treatment haven’t given them relief, like physical therapy, pain management or various forms of medication.
Dr. Thomas: What is new in the field of spinal surgery?
Dr. Tahernia: The trend has been to provide minimally invasive surgical techniques and do motion-sparing surgery, a technique used on qualifying patients to maintain range of motion rather than doing spine fusion. Fifteen years ago, we were one of the first sites to do cervical disc replacement. It's been FDA-approved now for several years. We have 10-year data we've collected on our patients and the information is very promising. Currently, we’re doing research on lumbar facet joint replacements — a new technology that is not FDA-approved — but we're one of 30 sites nationally performing these replacements. Along with motion-sparing, I think the goal of any kind of surgery is to achieve the surgical goal with as minimal trauma from the surgery itself as possible, to help accelerate recovery.
Dr. Thomas: It seems like a lot of the new technologies are helping to facilitate more motion-sparing than prior techniques. Perhaps you could discuss these options.
Dr. Tahernia: One of the things that is a time-honored way of treating painful motion segments has been spinal fusion, something that still works very well. But one of the downsides of having a spinal fusion is the potential development of adjacent segment degeneration requiring additional surgery in the future. One of the goals in selected patients is to try to maintain that motion. If you can maintain motion in the cervical or the lumbar spine and solve a surgical problem, then hopefully you will prevent degenerative changes occurring at adjacent segments and prevent additional future surgery.
Dr. Thomas: Do robotics play a role in spine surgery today?
Dr. Tahernia: Robotics doesn't play as big a role in spine surgery as it does in total joint replacement. We use navigation, which allows you to make adjustments in real time to direct, or to redirect, hardware appropriately. Because sometimes when you do these very complex surgeries, the normal anatomy is obscured. If you do revision surgery, you may have no normal anatomy to use, so augmented reality has a future.
Dr. Thomas: Is it similar to using an electromagnetic navigational system?
Dr. Tahernia: It's marking different points on the spine, running a CT scan and feeding those points into a system that allows you to use a headpiece to communicate with the system. It allows you to more accurately place the instrumentation in those complicated cases. We've been placing instrumentation without this technology for some time and we've done it very accurately, but any well-trained spine surgeon will tell you there are going to be some cases that are very complicated, and having this technology provides a safer way of getting it done.
Dr. Thomas: So, you’ve been able to improve outcomes with this navigation technology?
Dr. Tahernia: Yes, certainly in the very complicated cases. Once you put all your anatomic points into the system, it helps expedite the surgery as well.
Dr. Thomas: What kinds of challenges do you face in your practice?
Dr. Tahernia: Technology is always changing which makes it exciting. I think the challenge is to make sure you stay current on the latest technology.
Dr. Thomas: Moving on to Dr. O'Connell — how complex is the hand and the wrist?
Dr. O'Connell: The human hand consists of 29 bones, 29 joints, 123 ligaments, 34 muscles and 48 nerves. If you combine those anatomical facts with a very active desert lifestyle, synonymous with golf, tennis, and biking, it's easy to understand why 25 percent of athletic injuries occur in the hand and wrist, and 35 percent of the orthopedic trauma coming into the emergency room, is upper extremity trauma, such as the shoulder, which I treat. Hands are very complex and everything's a lot smaller, but the hand is an absolute marvel of anatomy. It's a part of our personality. We use our hands to make a living and perform sports, so it's part of who we are as a person and what we do as a career. Hands are an important part of our lives, and I love taking care of them.
Dr. Thomas: What piqued your interest in this field originally?
Dr. O'Connell: Hand surgery is very creative. For example, joint replacements in general are very complex, each case is challenging and that keeps it interesting. But with upper extremities, we do hundreds of different kinds of operations between the hand and the shoulder. We do fracture management, nerve surgery, and microscopic surgery; anything from a replant, nerve repairs and nerve grafting to ligament injuries, vascular injuries with revascularizations and artery problems. We take out tumors, we bone graft, we do muscle and skin flaps, skin grafts, and we do plastic surgery procedures as well. So, there's great complexity, it's never boring, and each case — especially trauma — is a little creative. For example, we have to get creative with an amputation of a thumb and a finger. Perhaps the thumb is not viable but the index finger is still viable, so with the replant, we make the index finger become a thumb.
Dr. Thomas: That’s really fascinating.
Dr. O'Connell: We make the index opposable so that it can function as a thumb. You look at what you have and create the closest thing to the normal hand you can accomplish.
Dr. Thomas: What are some of the more common reasons somebody would come in and see you as a hand and wrist and shoulder surgeon?
Dr. O'Connell: The most common things I see are basic carpal tunnel syndrome and trigger fingers, but trauma is very common as well. In the hand, we may put together a fracture with a screw that's one millimeter in diameter, which means the drill is 0.8 millimeters.
Those small screws and plates allow us to reconstruct a finger or the wrist, the carpal bones, to allow early motion and rehabilitation. Because, when you injure the hand, the energy that breaks the bone also goes through the tendons, ligaments, nerves and arteries, everything that moves. The trauma is more complex than just the bone itself, so you have to rehabilitate the soft tissue as well. The fixation [stabilization] of fractures in the hand or wrist or other parts of the body, allow us to perform early motion and early rehabilitation because the bones themselves are stable with the fixation. We see a lot of wrist fractures, finger fractures and clavicle fractures that we do internal fixation for.
Dr. Thomas: Do you do joint replacements in the shoulder?
Dr. O'Connell: We do a lot of shoulder replacements at the Center, either anatomic replacements or reversal replacements. I mostly do rotator cuff surgery and most of the arthroscopic reconstructions. Shoulder replacements, especially over the last decade, have really come to be equivalent to the outcome we get with hip and knee replacements. That wasn't true 20 years ago. Someone with an intact rotator cuff can have an anatomic replacement with a socket and a ball, just like a hip replacement would be.
Frequently, however, patients who develop severe arthritis of the shoulder have an incomplete rotator cuff tear, probably one that's been torn, maybe irreparable, and then the patient gets arthritis after that. Fortunately, in the last 10 years, there have been tremendous gains in the procedure called a reverse shoulder replacement. We make the socket a ball, and the ball a socket, effectively moving the center of rotation of the joint so the deltoid muscle, which is still intact, can accomplish lifting the shoulder overhead, so you don't need the rotator cuff anymore.
Dr. Thomas: Are those done robotically, the shoulder replacements?
Dr. O'Connell: We're working on that right now. One of our physicians, Dr. St. Pierre, is working with a company to develop the robot to do some cuts of the shoulder bone. That's probably two to three years away at the earliest. We do all rotator cuff repairs arthroscopically and there's been tremendous gains with that. We use implants that allow us to reattach the tendon back down to the bone. Some of our implants, which used to be metal, are either made of a material called PEEK [polyaryletherketones] — a kind of composite plastic, or even bioabsorbable materials — or materials that become bone.
Dr. Thomas: How important are body mechanics and ergonomics as far as preventing some of these injuries that you see?
Dr. O'Connell: With repetitive strain problems we see in the hand, proper positioning with your wrist and slight extension, and your elbow at about 70 degrees, puts the worker at a better position to withstand those repetitive motions. With the shoulder, people tend to weaken their rotator cuff as they get older, just through degenerative changes. It's a process we all experience. By the time you're 70 years old, nobody has a normal MRI anymore, and most people are never symptomatic. The people who tend to get a little weaker in their rotator cuff and lose the stability of the glenohumeral joint, can frequently be treated with rotator cuff strengthening exercises.
In studies done with people with rotator cuff tears who go to therapy, 75 percent are satisfied with therapy, and they usually see improvement within eight weeks. If you do physical therapy with a rotator cuff tear and you're not improving after eight weeks, the literature would suggest that you may be better off having a rotator cuff repair.
Our job is to figure out the people who can benefit from a non-surgical approach using physical therapy, modification of activities and strengthening the rotator cuff.
Dr. Thomas: Dr. Diltz, what are some of the more common injuries that you see in your practice as a sports medicine physician?
Dr. Diltz: As Dr. O’Connell mentioned about his specialty, the same would apply to mine. It's a very diverse field and a very diverse group of people. I'm always trying to find new ways to get patients back into their sport of choice.
My fellowship was in sports medicine, but I also did some work at Boston Children's Hospital, taking care of younger patients. I remember helping many patients who just wanted to get back to playing with their friends, to get back to their sport. Helping them do that was really rewarding.
Dr. Thomas: What are some of the new technologies available for sports related injuries?
Dr. Diltz: With ACL [anterior cruciate ligament — one of the strong bands of tissue that helps connect the femur to the tibia] injuries, we now put the tunnel positions in a much more anatomic position. One of the biggest changes is reconstructing ligaments — we're supporting the structures as they heal. There's something called an internal brace, and I’ve been putting those into ACL repairs for the last four or five years. And it's amazing. These patients feel much more solid at three months. There’s a thick band that helps to protect the ACL as it incorporates and becomes more normal anatomy. That's probably one of the bigger changes I've done.
I also do a lot of meniscus repairs and there's a new device that uses all sutures. Previously, we used a type of plastic, and I worried that if it were dislodged, it could damage the knee joints. Now we're doing soft tissue repairs of the meniscus with really good results. When you repair a meniscus and you do an ACL surgery in conjunction, the rate of healing of that meniscus goes up exponentially.
Dr. Thomas: Regarding orthopedic biologics — bone graft and growth factors, stem cells, platelet-infused plasma, autologous blood, and autologous controlled serum. How do these play a role in what you do now?
Dr. Diltz: I think it's really exciting for every specialty in orthopedics, definitely in sports medicine, trying to find ways to optimize healing. Right now, it's the Holy Grail, as far as the cartilage is concerned. Cartilage is avascular, so it doesn't have a great healing potential, but if we could find a way to inject something to rejuvenate the cartilage, instead of having to replace it with metal and plastic, I think everybody would be excited.
Dr. Tahernia: With the spine, we're always looking at different ways to treat those injuries. First of all, whenever we do a fusion surgery, we want to make sure we’re successful, because one of the biggest costs to health care involving spine injuries is a fusion surgery that doesn't heal or needs to be redone. We have many options to help facilitate that. But going back to the biologics, we’re looking at different bone morphogenic protein products. We've found many synthetic products that work as well as the patient's own bone. For years, harvesting the patient’s own bone has been the standard of care, but 25 percent of people who had an iliac crest bone graft performed had constant pain from the harvesting site alone, so now we have other technology that works just as well.
The bone morphogenic proteins have been around a long time, but we're always looking at other products that can help achieve a solid fusion. The question is, how can we stop a degenerative cascade from beginning in the first place? For the spine, it really starts with the disc space. The disc is the most important structure in any motion segment in the spine, and if there's a way to regenerate disc material and allow the degenerative process not to proceed, then I think you're going to keep a lot of people from developing disease requiring surgical intervention. But the big challenge, similar to many different parts of the body, is that the disc space is very avascular. How do you get a product that you can inject into the disc to behave like a normal disc, or to have it regenerate cells and regenerate an environment that has a good blood supply?
Dr. O'Connell: One of the technologies that truly improved hand surgery is nerve grafting. We typically take small neural tubes from the side of the foot — the sural nerve — to fill a defect after a nerve injury using sutures thinner than human hair. We can now achieve nerve continuity without taking a nerve from somewhere else in the patient’s body. It’s very exciting and has improved dramatically.
Dr. Diltz: Speaking of biologics, we've done a lot in the way of cartilage transplants that we weren't doing before. I just saw a young, 30-year-old patient who was a collegiate soccer player and has a cartilage defect, and we're going to do a living donor transplant. Once you have a matched donor, based on the diameter of the condylar of the femur, you have about five days to transplant the living cells. I've done this procedure before on a 26-year-old. There are many new, exciting things we're doing in the way of cartilage and biologics.
Dr. Thomas: Let’s talk about prevention. Dr. Diltz, you see a lot of people with meniscal tears and ACL injuries. What do you tell people to do to stay healthy and maybe less prone to injuries?
Dr. Diltz: I think there will always be injuries. It may seem counterintuitive, but some of the people I see with the healthiest knees, cartilage and meniscus, are some of the most active ones. I'll see a runner in his late 60s or 70s, and when you see the X-ray of his knee, you can't believe it's from a 70-year-old because the knee looks so good. I think it's all moderation and I think that it's important to stay active. If people become sedentary to protect their knees, those knees may be the ones to wear out the quickest. One of the things we strive to do here is to find ways to keep people remaining active later in life. And that's prominent throughout the desert — people playing tennis, pickle ball and golf, much later into their years than they thought possible.
Dr. Thomas: So, it is important to partake in more continuous activity rather than weekend warrior type stuff.
Dr. Diltz: Yes.
Dr. O'Connell: If we look at professional athletes, they are very rigid about their pre-activity routine and I think the weekend warriors don't necessarily do that. One of the main reasons people get injured is not being prepared. A good stretching program before exercising, and maintaining good strength and conditioning, are going to help prevent many injuries from occurring.
Dr. Thomas: Dr. Tahernia, how does posture play a role in preventing injury to the spine?
Dr. Tahernia: Having a strong core and being aware of your posture is really important. I echo everything already said — exercise with moderation, but specifically concentrate on your core — use a combination of a good core exercise program and aerobic conditioning.
One cause of tremendous disability is a lack of sagittal alignment, meaning the loss of having your head sit directly over your pelvis. Sometimes it’s genetic or based on trauma, but I'm sure posture over a lifetime affects it as well. If your head sits well in front of your pelvic region, the amount of stress on your back and the amount of back pain you experience is almost directly proportional to the amount of malalignment you have. Posture is very important.
Dr. Thomas: What has robotics done for the field of orthopedics?
Dr. O'Connell: We have four robots now, so it's a very active part of our joint replacement program. The patient is X-rayed, a CT scan is done prior to the procedure and that data is fed into a computer, which then determines the appropriate bone cuts necessary to limit the amount of bone removed and enable the most appropriate size implant to be placed.
The surgeon holds the saw, but the robot guides the exact cuts, so it's safer, potential injury is decreased, and the alignment of the bone cuts are exact. The implant is then placed by the surgeon. Essentially, the robots are used for the bone cuts in joint replacement patients, with good success and excellent outcomes.
Dr. Thomas: I can see where there's been this drive to develop things like robotics, where you are making smaller cuts to minimize pain post-operatively and increase efficiency overall, and customize joint replacements, which probably helps with post-op pain and outcomes. Are there other developments in post-op pain management that allows for more outpatient type procedures?
Dr. Tahernia: It goes back to the pre-surgical screening process. We're better at engaging our patients preoperatively, and if they know what their expectations are postoperatively, they're going to have a better outcome. The unknown can be scary to patients who have complicated surgeries, and if you can guide them through the process before they experience it, I think you get a better experience post-op. This includes engaging their family members as well.
Dr. Diltz: Anesthesiologists have made great progress in finding ways to numb the areas we're working on. It's common with sports medicine procedures and total joint replacements to do a nerve block where it numbs a specific area. We also have new products that help reduce bleeding.
Dr. O'Connell: Working together as a team with our nurses, anesthesiologists, surgeons, as well as the patients, we standardize what we do. If you want all your rotator cuff repair patients to go home, they need to go home comfortably. Patients get a nerve block which may last anywhere from five to 18 hours, so they're going to be able to leave the hospital comfortably. The patients are going to know what to expect up front, which is what we do in the pre-op classes. We’ve standardized the operations and the pain management so they can successfully go home.
Dr. Thomas: You also have pain specialists in your practice.
Dr. O'Connell: We have three pain management specialists who are all partners in our group, and they're experts at doing outpatient pain management. If we have patients with nonsurgical problems who need pain management, our specialists take care of them using a variety of treatments.
Dr. Thomas: In addition to the Total Posterior Spine System (TOPS) research led by Dr. Tahernia, what other kind of research is happening at EDOC?
Dr. Diltz: We have a registry where we follow some of the outcomes of the biologic treatments. When you're doing new and innovative things in a field, you need due diligence to follow the patient's outcome. We want to give future patients an idea of how these treatments work.
I know Dr. St. Pierre has ongoing research. In sports medicine, we're one of four centers looking at injecting a type of bone filler into the hip for insufficiency fractures or subchondral edemas.
Dr. O'Connell: We have a large practice and each person at the practice has different research ideas and projects they're involved with — 17 physicians and 17 physician assistants, and we're adding another physician by the end of the calendar year.
Dr. Thomas: Tell me about the new expansion to EDOC.
Dr. Tahernia: Having a new surgery center and a state-of-the-art facility, we're able to bring in new technology and implement it.
Dr. O'Connell: With the new expansion, we now have six new operating rooms that are absolutely state-of-the-art. The two previous operating rooms are being updated to have the same technological advances. So, we'll have eight operating rooms, and 19 preoperative and postoperative bays. We'll have the ability to keep patients overnight for 23-hour stays, if need be.
Everything from pre-admission testing to physician/patient visits, preoperative workup and surgeries will be done here.
We've also added 25,000-square-feet of clinical space, with new areas for physical therapy, occupational therapy, an extra 19 more examination rooms, and a new MRI. We have our own little café where you can have a latte while you're waiting. It's a really fantastic facility that we're blessed to have made possible through the generosity of our donors here at Eisenhower. We're all very grateful.
Dr. Thomas: Any vision for the future, 10 to 20 years down the road?
Dr. Diltz: In my 11 years here, EDOC has been pretty amazing about staying current with the times. This new facility is a testament to what Eisenhower donors have allowed us to do. We have the best technology possible at our fingertips.
Dr. Tahernia: As we partnered more closely with Eisenhower, it has allowed us to build the program that we have here, and I think it's a very attractive option for physicians and other clinicians just completing their training and fellowships. We've been very successful recruiting top-notch people.
Dr. O'Connell: This facility we've been able to develop with Eisenhower and the generosity of the donors is second to none. I think it will allow us to attract even more orthopedic surgeons. We're on the same list as UCLA or Cedars Sinai for the top hundred Medicare hospitals in the country. There are five million people who live within 90 minutes of here, and many of those people seek their health care on the West Coast. They need to know there is an equivalent, if not better organization, in orthopedic surgery and medicine in general, here at Eisenhower.
For more information or to find a physician at Eisenhower Desert Orthopedic Center, call 760.773.4545. Or visit EisenhowerHealth.org/EDOC.