#8 M op sh
in e e
th s t dic
e o s
A publication from
Midwest Orthopaedics at Rush
he first year of operation for Midwest Orthopaedics at Rush (MOR) was
2004, and it turned out to be a very good one. We carried that momen- www.rushortho.com
tum into 2005 and have some exciting initiatives and changes in progress.
First and foremost, we are welcoming four new physicians to our organization.
Central DuPage Hospital
Two of those physicians, Steve Gitelis, MD, and Walt Virkus, MD, are well
known to us, having been colleagues at Rush University Medical Center for
25 North Winfield Road
many years. The addition of Drs. Gitelis and Virkus is especially exciting because it expands our serv- Winfield, IL 60190
ices to include nationally recognized orthopaedic oncology and orthopaedic trauma care. The addition Toll free: (877) MD-BONES
of these two specialties brings us closer to our goal of providing the most comprehensive orthopaedic Phone: (630) 682-5653
services in the nation. Fax: (630) 682-8946
We also have longstanding relationships with the other two physicians joining our group — Kern
Singh, MD, and Trish Palmer, MD — as both completed residencies at Rush before pursuing post-
graduate fellowships and careers. Dr. Singh is subspecializing in the spine and will work out of both Chicago — South Loop/River City
our downtown and Winfield/Central DuPage Hospital offices. Dr. Palmer joins us from the University 800 South Wells, Suite M30
of Utah Department of Family and Preventive Medicine, where she was an Assistant Professor. Chicago, IL 60607
Dr. Palmer will join our Sports Medicine team, where she will work closely with Kathy Weber, MD. Toll free: (877) MD-BONES
Other initiatives in progress that we feature in this issue include the development of our Spine Center Phone: (312) 431-3400
at Rush; our use of new, Internet-based, patient education programs (EMMI); and our approach to Fax: (312) 427-6116
handling pediatric orthopaedics given the recent relocation of Jeffrey Sawyer, MD.
We are also in the process of opening a new Winfield facility, which is planned to open in early
Oak Park Hospital
September. This new office triples our clinic space at Central DuPage Hospital (CDH) and is located in
the beautiful new physician pavilion on the campus. We expect this facility will allow us to greatly
Medical Office Building
expand the volume and breadth of services provided in Winfield and at CDH. This expansion is also 610 South Maple Avenue, Suite 1400
exciting because it is our prototype paperless and filmless facility. We will provide our own in-house and Oak Park, IL 60304
completely digital imaging, and we plan to roll out our electronic health record system here as well. Toll free: (877) MD-BONES
We are currently introducing the digital imaging approach at all MOR locations, and by the end
Phone: (312) 243-4244
of the year, physicians will have the ability to view digital images from multiple locations, including Fax: (312) 942-1517
In a manner similar to the Chicago White Sox and Chicago Bulls, for whom we serve as team physi- RUSH University Medical Center
cians, MOR strives for continuous improvement in our practice. All the improvements and changes
1725 West Harrison Street, Suite 1063
we make are for the single goal of providing higher-quality and more efficient patient care. And to
do this, we understand that efficient and effective communication with all our referral sources is
Chicago, IL 60612
imperative. So I urge each and every one of you to call or e-mail if you have any ideas or issues Toll free: (877) MD-BONES
regarding the improvement of communications between our groups. Phone: (312) 243-4244
Fax: (312) 942-1517
We look forward to continuing our relationship with you and providing the highest level of patient
care and service possible.
About the cover: Photo courtesy of
Sincerely, Illinois Bureau of Tourism;
*As featured in U.S. News and World
Charles A. Bush-Joseph, MD Report “2005 Best Hospitals Edition”
Managing Member, Midwest Orthopaedics at Rush
2 Orthopaedic Excellence
Physician Listing Chairman’s Letter
Howard An, MD Joshua Jacobs, MD
Spine, Back, and Neck Joint Reconstruction
Gunnar Andersson, MD
Spine, Back, and Neck
Bernard Bach Jr., MD
Simon Lee, MD
Foot and Ankle
Gregory Nicholson, MD
T he Spine and Back Center at Rush — It's how
spine and back care should be.
I am proud to announce that the spine section of
Midwest Orthopaedics at Rush has joined Rush
Sports Medicine Sports Medicine and Shoulder
University Medical Center to form The Spine & Back
Center at Rush. This joint venture among Midwest Orthopaedics at Rush,
Richard Berger, MD Trish Palmer, MD
Orthopaedics and Scoliosis Ltd., and CINN will bring together the talents of
Joint Reconstruction Sports Medicine and Women’s
orthopaedic surgeons, neurosurgeons, physiatrists, and spine nurse special-
Sports Medicine ists to provide the most comprehensive spine program in Chicago.
Charles Bush-Joseph, MD
Sports Medicine Wayne Paprosky, MD Ranked higher than any other hospital in Illinois by U.S. News & World
Joint Reconstruction Report in 2004, the Department of Orthopaedic Surgery and the
Mark Cohen, MD
Department of Neurosurgery and Neuroscience come together at The Spine
Hand and Elbow Frank Phillips, MD & Back Center at Rush to treat spine, back, and neck degeneration and
Spine, Back, and Neck deformity with the latest in conservative and surgical treatment options.
Brian Cole, MD
Sports Medicine, Cartilage Anthony Romeo, MD The Spine & Back Center at Rush opened in March 2005 and is located in
Restoration Sports Medicine, Elbow, Suite 118 of the Professional Building of Rush University Medical Center.
and Shoulder Midwest Orthopaedics physicians participating in The Spine & Back Center
Craig Della Valle, MD at Rush include Gunnar Andersson, MD; Edward Goldberg, MD; Howard
Joint Reconstruction Aaron Rosenberg, MD An, MD; Frank Phillips, MD; Yejia Zhang, MD; Kern Singh, MD; and April
Joint Reconstruction Fetzer, MD. To make an appointment with one of these physicians, call
John Fernandez, MD (312) 243-4244.
Hand and Elbow Mitchell Sheinkop, MD
Joint Reconstruction Sincerely,
April Fetzer, MD
Physical Medicine/Pain Kern Singh, MD Gunnar Andersson, MD, PhD
Department of Orthopaedic Surgery
Management Spine, Back, and Neck
Rush University Medical Center
Joseph Fillmore, MD Scott Sporer, MD
Physical Medicine/Pain Joint Reconstruction
Nikhil Verma, MD
Jorge Galante, MD Sports Medicine and Shoulder
Walter Virkus, MD
Steven Gitelis, MD Orthopaedic Oncology/Trauma
Kathleen Weber, MD
Sports Medicine and Women’s
Edward Goldberg, MD Sports Medicine
Spine, Back, and Neck
Yejia Zhang, MD
George Holmes Jr., MD Physical Medicine/Pain
Foot and Ankle Management
Orthopaedic Excellence 3
In this issue
Setting the Stage for Injury
Epidemiology and Etiology of Achilles Tendinopathy
By George B. Holmes, MD...................................................................................................................... 6
Volume 1, Issue 2 Straight from the Shoulder
A Look at Arthroscopic Rotator Cuff Repair
By Brian J. Cole, MD, MBA, and Paul Lewis, MS .............................................................................. 8
Improving Survival Rates with Orthopaedic Oncology, Trauma, and
By Steven Gitelis, MD, and Walter Virkus, MD ............................................................................... 12
Best in Class
Rush Orthopaedics Ranks #1 in Illinois
By Zachary Settle ................................................................................................................................ 14
Motion-Sparing Spine Technology
Examining Disc Replacement and Low Back Pain
By Kern Singh, MD ................................................................................................................................. 16
Total Hip Arthroplasty Using
Porous-Coated Acetabular Components
Long-Term Studies Demonstrate Effectiveness
By Craig J. Della Valle, MD................................................................................................................. 20
Microprocessor Prosthetic Knee
A Step Forward at Rush:
The First Hip Disarticulation C-Leg Prosthesis
By James A. Kaiser, BS, CP/L ............................................................................................................ 22
When It’s Time to See a Specialist
By Beth Healy, CRC/R, CEAS .............................................................................................................. 24
16 Big Plans for Pediatric Orthopaedics
and Midwest Orthopaedics at Rush ............................................................................. 26
Surgeon Treats Haitian Patient with Clubfoot
By Lisa Files ........................................................................................................................................... 27
Preventing Malpractice Suits While Educating Patients
Does It Get Any Better Than That?
By Dennis Viellieu ................................................................................................................................ 28
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22 The information contained in this publication is not intended to replace a physician’s professional consultation and assessment.
Please consult your physician on matters related to your personal health.
4 Orthopaedic Excellence
Orthopaedic Excellence 5
Setting the Stage for Injury
Epidemiology and Etiology of Achilles Tendinopathy
By George B. Holmes, MD
lthough much of the literature on Achilles What do these findings mean for the clinician? At These factors, considered as a conglomerate,
tendinopathy, including rupture of the a minimum, they should encourage orthopaedic appear to have an important association as risk
Achilles tendon (AT), focuses on the mechan- surgeons as well as primary care physicians to factors for the development of Achilles tendinosis.
ical aspects of injury, chronic diseases such as closely examine the associated chronic diseases of
diabetes, hypertension, and obesity often create patients with ruptures of the AT. It is especially Achilles Tendon Characteristics
the microvascular deterioration that sets the stage important to take a detailed, thorough history of
The AT is the strongest tendon in the human body,
for injury. the patient and to adhere to strict measures to
with a tensile strength between 50 to 100 N/mm
maintain the vascularity of the AT.
In active persons and athletes, the use of oral and and is formed by the joining of the two tendons of
transdermal steroids can also create microvascular In addition, because evidence indicates steroids the soleus (dorsally) and the gastrocnemius (ven-
disease that creates a risk factor for injury as well have a similar type of damaging effect on the trally). The two merge into each other and rotate
as potential wound complications if surgery is vascularity of the AT as diabetes, obesity, and simultaneously to form a compact tendon. Despite
undertaken shortly after the injection of steroids in hypertension, clinicians should understand that its strength, the AT is a commonly ruptured ten-
or around the AT. Ruptures of the AT are relatively we place patients at risk whenever we give them don in the human body. If the tendon is length-
infrequent, while Achilles tendinosis is not usually steroids. In fact, many athletes with a rupture of ened more than 3% to 4%, its fibers begin to dis-
a result of overuse but most often occurs in older, the AT have histories of steroid use. rupt. Rupture occurs after an increase of 8%.
less athletic patients.
Diagnosis of a torn AT is often difficult for a Unlike other tendons of the ankle that have a
nonspecialist, resulting in patients visiting sinovial sheath, the AT is enveloped by a
When the factors of orthopaedic surgeons at differing postinjury paratenon membrane that consists of two layers:
hypertension, obesity, and stages, usually after an initial nondiagnosis. When a deeper layer surrounding and in direct contact
examined soon after the injury, the gap is often with the epitenon and a superficial layer called the
diabetes are considered obliterated by edema and scar tissue, making peritenon, connected to the underlying layer
together, there is a palpation unreliable. through the mesotenon. The paratenon originates
significant association In another study exam-
between these disorders ining etiologic factors
associated with symp-
and rupture of the AT. tomatic Achilles tendi-
nosis, we found 98%
When two colleagues and I conducted a retro- of the men and 76% of
spective, multicenter study of 58 patients with the women in our
spontaneous rupture of the AT, we found that group of 82 patients
53% of the patients who were aged 50 years or had hypertension, dia-
older had hypertension, 35% were obese, 24% betes, or steroid expo-
had taken steroids, and 23% had diabetes. The sure. We studied 82
average age of the group (39 males and 19 patients identified with
females) was 41 years. Analysis indicated a statis- Achilles tendinosis (38
tically increased incidence of degenerative factors males and 44 females)
in the older population. with an average age of
50 years. Twenty-two
In addition, there was a significant correlation of the men were deter-
between Achilles ruptures and hypertension in this mined to be obese
group. When the factors of hypertension, obesity, (defined as a body
and diabetes are considered together, there is a mass index greater
significant association between these disorders than 30), while 27% of
and rupture of the AT. the women were obese. Medial ankle and foot; (inset) foot raised as in walking, medial view
6 Orthopaedic Excellence
or some combination of these from a variety of
causes. These can include aging, microtrauma, and
OrthoFact vascular compromise. The Footwear Factor
Common Foot and Ankle Injuries:
From a histologic standpoint, there is noninflam- Proper footwear is key in preventing,
¥ Ankle Sprains. When the foot turns inward matory intratendinous collagen degeneration with
(ankle inversion) from a fall, tackle, or jump, recovering from, and preventing recur-
fiber degeneration and thinning, hypercellularity, rence of AT injuries. On the other hand,
an ankle sprain is usually the result.
scattered vascular ingrowth, and increased interfib-
¥ Achilles Tendon Injury. Sports that tighten poorly fitted shoes can increase the
the calf muscles, such as basketball, run- risk of AT injuries, impede recovery, and
ning, and high jumping, can cause a strain Although degenerative factors are strongly associ- put you at risk of recurrent injuries.
(Achilles tendinitis) or a rupture. ated with AT ruptures in middle-aged and older
There is more to finding the right fit than
¥ Overuse Injuries. Excessive training, such as patients, a study has yet to examine all at-risk
size and width. Adequate cushioning,
running long distances without rest, places patients to determine which are asymptomatic
with degenerative changes. We have not screened
arch height, and pronation are all factors
repeated stress on the foot and ankle,
resulting in stress fractures and muscle/ people with diabetes, hypertension, and other risk to consider when selecting shoes.
tendon strains. factors with MRIs for an assessment of the pres- Some people benefit from adding extra
¥ Shin Splints. Over training, poorly fitting ence of these degenerative changes in otherwise cushioning under their heels, which
athletic shoes, and a change in running asymptomatic patients. reduces the length the AT stretches
surface puts athletes at risk for stress Contributing Risk Factors with each step. This is temporarily
fractures, or shin splints. beneficial during injury recovery, but
Ruptures of the AT occur most frequently in mid-
dle-aged men. Although earlier studies that permanent use of increased cushioning
from the deep fascia of the leg (fascia cruris), focused primarily on diagnosis and treatment did can actually lead to additional injuries,
which covers the tendon posteriorly. not thoroughly document any associated medical as it can shorten the AT’s length.
disorders, our work has found correlations with (in
A laser Doppler flowmetry microvascular perfusion descending order) hypertension, obesity, exposure Finding shoes with the right arch sup-
study of the AT demonstrated a comparatively to corticosteroids, and diabetes. port for your foot can seem like an
lower blood flow near the calcaneal insertion, impossible task. Feet with low arches
with otherwise even distribution throughout the Obese patients are at greater risk for the develop- and feet with high arches both increase
tendon. Other studies have shown an uneven ment of diabetes than patients who are not obese. the risk of AT injuries. If your shoes do
increase in blood flow with exercise. Patients who are obese and diabetic are also more not have adequate arch support built in,
likely to be hypertensive than patients who are not arch-support inserts are an inexpensive
Repetitive overload of the tendon beyond its phys- obese and not diabetic.
iological threshold may produce inflammation of way to get a customized fit.
the AT sheath, degeneration of its body, or both. Also, atherosclerotic disease of both large and With each step we take, pronation, or
Even if the AT is repeatedly stressed within its small vessels is common to both hypertension and the rotation of the foot inward and
physiological limits, damage can occur if sufficient diabetes. Evidence suggests that hypertension downward, is taking place. While this is
time for repair is not allowed. Recovery from may increase the risk of developing diabetes. normal, excessive pronation, also
tendon injury is slow because of low oxygen con-
Thus, the interrelationship between hypertension, known as hyper mobile feet, can lead to
sumption, slow synthesis of structural protein, and
diabetes, and obesity is obvious although compli- pain and injury. Antipronation, or
excessive load. Oxygen consumption of tendons is
cated. Microvascular, anatomic dissection, injec- motion-control, shoes can help
7.5 times lower than that of skeletal muscles, even
tion, and hydrogen washout studies clearly show decrease the excessive activity around
though tendons are able to sustain loads many
a decrease in local vascularity in AT ruptures. There the AT, as well as the ankle and subtalar
times the body weight.
is strong evidence, therefore, that obesity, hyper- joint, with their firm midsoles, board
Challenging Diagnosis tension, diabetes, and exposure to steroids may
lasting, rigid heel counters, and non-
Diagnosis of AT rupture is challenging and should diminish small vessel vascularity. flared heels.
be made by the general orthopaedist as well as the George B. Holmes Jr., MD, a board-
foot and ankle orthopaedist. Patients may report For some people with more severe AT
certified orthopaedist, received his
they felt as if they had been struck at the back of injuries, such as a tendon rupture, a
medical degree from Yale University. He
the heel and may have heard a snapping sound. completed two years of general surgery temporary brace may be required to
They are usually unable to bear weight on the at Columbia Presbyterian Hospital in immobilize the AT. These range from
effected limb because of pain and/or weakness. New York City. He then completed his orthopaedic light-support wrap braces to complete-
residency at Harvard University and Massa- immobilization braces.
Tendinosis may be asymptomatic. Most patients chusetts General Hospital in Boston. Dr. Holmes
with an AT rupture did not have clinical pictures of completed fellowships in both foot and ankle sur- Consult your physician before consider-
tendinopathy before their ruptures. Tendinosis is gery at Midwest Orthopaedics at Rush in Chicago. ing any specialized insert, footwear, or
defined as intratendinous degeneration hypoxic, He has held a position on the editorial board of brace for an AT injury.
mucoid or myxoid, hyaline, fatty, fibroid, calcific, Foot and Ankle International since 1989.
Orthopaedic Excellence 7
A Look at Arthroscopic
Rotator Cuff Repair
By Brian J. Cole, MD, MBA, and Paul Lewis, MS
aron Sele, pitcher for the Anaheim Angels, left the 2002 season
early complaining of soreness in his right shoulder. It was later
determined that the cause of this pain was a tear in his rotator cuff.
Following arthroscopic surgery, he returned to the Angels and had a suc-
cessful 2003 season. In addition to athletes such as pitchers, swimmers,
and tennis players, workers who perform overhead activities, including
painting, stocking shelves, and construction, are prone to tears in their
A tear in the shoulder’s rotator cuff, whether it is partial or full thickness,
can occur because of a sudden injury (e.g., a fall or sudden jerklike lift-
ing) or develop slowly from joint overuse. Most rotator cuff tears occur
in the supraspinatus at the tendon’s insertion site just posterior to the
biceps tendon (the “critical zone”).
This junction has a relatively poor blood supply, making the rotator cuff
tendons especially vulnerable to degeneration with aging. This may
explain why rotator cuff tears are fairly common after the fifth decade.
Diagnosing a rotator cuff problem requires a thorough review of the
patient’s symptoms, a physical examination, x-rays, and magnetic reso-
nance imaging (MRI). It is more common in our practice to see patients
over the age of 40 years with gradually worsening symptoms due to
rotator cuff damage. Although their complaints may include shoulder
weakness and pain, many patients with known rotator cuff tears have
surprisingly few symptoms.
When the tear occurs with an injury, there is often sudden acute pain, a
snapping sensation, and an immediate weakness of the arm. The patient
may feel radiating pain down the side of the arm that persists even
when the patient is not engaged in any lifting or reaching activities.
Other symptoms may include stiffness and loss of motion. Patients may
also complain of difficulty sleeping due to pain, especially when they lie
on the affected shoulder.
As the disease progresses, discomfort and stiffness increase. Sometimes
a catching sensation is felt when the arm is lowered. Weakness and
inability to raise the arm, as well as severe night pain, may indicate a
rotator cuff tear.
8 Orthopaedic Excellence
On physical examination, the patient’s range of Shoulder and Elbow Surgeons [ASES] shoulder
motion or shoulder strength may be compro- score, and SF-12) to evaluate outcomes following
mised. Specifically, weakness in external rotation arthroscopic surgery in our first 30 patients.
with the arm in adduction or abduction may indi- Twelve months after surgery, the visual analog
cate a significant tear of the anterosuperior or scale for pain and all shoulder survey scores
posterosuperior rotator cuff tendons, respectively. improved significantly compared with the preop-
erative scores. There was continued significant
Other indications of a rotator cuff tear include improvement in these scores during the second
atrophy of the muscles around the shoulder, a postoperative year.
painful acromioclavicular joint, pain or weakness
Patients demonstrated significant strength
when lifting or lowering the arm, and crepitus
improvement in the affected shoulder as well. All
upon shoulder movement. Before treating the
patients reported that they would repeat the sur-
tendon tear, radiographs are useful to reveal any
gical and rehabilitation process to achieve the
evidence of arthritis, spurs within the shoulder,
same results. The level of functioning of the
loose bodies, fractures or fracture malunions, repaired shoulder was rated, on average, 85% of
avascular necrosis, and anterior or proximal migra- Superior view of the supraspinatus, the most frequently
the normal shoulder function. Other studies have
tion of the humerus. injured rotator cuff tendon
shown that the use of this procedure produces
good to excellent outcomes in more than 90% of
The use of MRI can sometimes distinguish The tendon edge is repaired to the humerus with
patients surveyed four to 10 years after surgery.
between a full-thickness tear of the tendon and a the use of “resorbable bone anchors.” Following
partial tear, whether the tear is within the tendon placement of between one and four anchors, the These outcomes need to be balanced against the
itself, or if the tendon is detached from bone. MRI sutures within the anchors are passed through the skill and experience of the surgeon. Arthroscopic
is also useful to determine the chronicity of the rotator cuff, and using specialized knot-tying tech- rotator cuff repair is a technically difficult proce-
tear by evaluating sagittal oblique views for mus- niques, the tendon is approximated to the bone dure, which limits its successful application to
cle atrophy or fibrous replacement. where it originated from prior to tearing. Our atten- experienced surgeons. >>
tion is then turned to splits within the tendon that
Unless there is evidence of a complete tear with are repaired by placing sutures to approximate the
minimal muscle atrophy or tendon retraction, initial
treatment options may include rest, limited over-
edges of the tear. Once we are assured of the OrthoFact
integrity of the repair, the instruments are removed, Shoulder injuries are often caused by sports
head activity, use of a sling, anti-inflammatory and the arthroscopic portals are closed. Patients are activities that involve excessive overhead
medications, steroid injections, strengthening exer- placed in a sling for comfort, and an ice compres- motion like swimming, tennis, pitching,
cises, and/or formal physical therapy. In the case of sion dressing is placed over the shoulder. and weightlifting. People involved in every-
an acute or chronic tear that fails nonoperative day activities like washing walls, hanging
Physical therapy to maintain and improve the curtains, and gardening also can get
management, surgery may be the best option.
range of shoulder motion begins immediately fol- shoulder injuries due to excessive overhead
Visualization Through Television lowing surgery. The initial discomfort following arm motion.
Arthroscopic rotator cuff repair is widely accepted the surgery gradually lessens over the first three to
Athletes are especially susceptible to shoul-
as an alternative to traditional open or mini-open four weeks, when the sling is ultimately discarded.
der problems. A shoulder problem can devel-
rotator cuff repair. The procedure is performed on Emphasis on passive range of motion and early op slowly in athletes through repetitive,
an outpatient basis under general anesthesia with muscle function is important for the first six to intensive training routines.
a regional nerve block for postoperative pain con- eight weeks. It takes about 12 weeks, however,
trol. Patients are typically discharged within two for the tendon to heal completely. What Are the Warning Signs of a Shoulder
hours of their operations. Injury?
We advise our patients that rerupture of the
repaired rotator cuff is possible if too much force If you are experiencing pain in your shoul-
The technical aspects of this procedure have been der, ask yourself these questions:
is placed on the tendon before it is fully healed.
substantially refined over the last five years. Four ¥ Is the shoulder stiff? Can you rotate your
Strengthening continues for four to six months,
arthroscopic portals (approximately 1 cm in arm in all the normal positions?
whereby patients are permitted to return to all
length) are made to allow for the insertion of a
activities in an unrestricted fashion. ¥ Does it feel like your shoulder could pop out
fiberoptic scope and small instruments. The scope or slide out of the socket?
is connected to a television monitor, and we per- Patient Follow-Up Study
¥ Do you lack the strength in your shoulder to
form the repair through manual manipulation of To evaluate the effectiveness of the arthroscopic
carry out your daily activities?
instruments and intra-articular video observation. rotator cuff repair procedure, we examined out-
If you answer yes to any one of these ques-
come data in nearly 400 patients who had under- tions, you should consult an orthopaedic
With the use of preoperative x-rays, we are able to
gone this procedure at Rush University Medical surgeon for help in determining the severity
appropriately debride the undersurface of the acro-
Center with a minimum of two years of follow-up. of the problem.
mion and flatten and smooth it to eliminate bony
impingement. Retracted tears are mobilized by We used objective strength testing and validated Source: American Academy of Orthopaedic Surgeons,
releasing soft tissue contractures arthroscopically. shoulder surveys (e.g., Constant, Rowe, American
Orthopaedic Excellence 9
While the vast majority of people undergoing rota- Brian J. Cole, MD, MBA, is an for the Chicago Bulls and a Co-team Physician and
tor cuff repair surgery have a positive outcome, Associate Professor in the Department consultant for the Chicago White Sox and Chicago
complications such as problems with anesthesia, of Orthopaedics as well as the Depart- Rush Arena Football team.
infection, retear, numbness in the arm, weakness, ment of Anatomy and Cell Biology at
and arthritis rarely occur. Shoulder stiffness and Rush University Medical Center in
Paul Lewis, MS, is a medical student at
loss of motion are also potential complications Chicago, Illinois. He received his medical degree Rush University Medical College and a
after rotator cuff repair when patients are not and MBA from the University of Chicago in 1990. graduate student in the Department of
He completed his residency at the Hospital for
compliant with postoperative rehabilitation. Anatomy and Cell Biology at Rush
Special Surgery in New York in 1996 and his sports
University in Chicago, Illinois. He received
Future Outlook medicine fellowship at the University of Pittsburgh
a bachelor’s degree in microbiology and chemistry
Small tears have a better outcome than larger tears. in 1997. from the University of Illinois in 2002. Mr. Lewis
If the tear is large, the extent of recovery Dr. Cole is the Director of the Rush Cartilage Res- aspires to pursue a medical career in orthopaedics
is not accurately predicted until the repair and reha- toration Center as well as the Head Team Physician upon graduation from Rush University in 2007.
bilitation are completed. Older tears (several months
or longer) are difficult or sometimes impossible to
repair due to poor tissue quality. In some instances,
transferring a local tendon to replace the lost func-
tion of the rotator cuff is successful in reducing pain
and improving function.
Arthroscopic rotator cuff repair provides superior
visualization and mobilization of the joint. A 3-D
assessment of both the degree and configuration
of the rotator cuff tear provides physicians with
the opportunity to formulate a strategy for repair.
Additionally, the arthroscope allows us to visualize
the bursal aspect of the rotator cuff and intra-
articular structures in an effort to diagnose and
treat concomitant pathology (e.g., labral tears,
cartilage defects, bicep tendonitis). By avoiding
the significant deltoid incisions required in open
procedures, an arthroscopic procedure results
in less postoperative pain and, therefore, less
need for prescription pain medication without
the complications of deltoid detachment or
In summary, the use of the arthroscope in the
repair of rotator cuff tears provides the advan-
tages of glenohumeral inspection, treatment of
intra-articular lesions, smaller incisions, no deltoid
incisions, less soft tissue dissection, less pain, and
more rapid rehabilitation.
Future developments in the treatment of rotator
cuff repair include novel arthroscopic instruments
that improve the efficiency and accuracy of the
procedure. Research is also being conducted on
“orthobiologic” tissue implants, which promote
growth of new tissue in the shoulder. We are
actively investigating means to stimulate local
growth factors at the time of repair and methods
to reinforce the rotator cuff to minimize the inci-
dence of retears. We remain encouraged that our
current results following arthroscopic rotator cuff
repair exceed our experiences following mini-open
repair, and we will continue to investigate novel
approaches to maximize our outcomes.
10 Orthopaedic Excellence
Orthopaedic Excellence 11
Improving Survival Rates with Orthopaedic Oncology,
Trauma, and Joint Reconstruction
By Steven Gitelis, MD, and Walter Virkus, MD
rthopaedic oncology, a small but growing clinically, and functionally the most broadly based, most have such clinical characteristics and radi-
subspecialty of orthopaedic surgery, has its multidisciplinary subspecialty of any of the ographic presentations that a reasonably accurate
roots in European medicine of the 1800s, orthopaedic subfields. The combination of devel- diagnosis can be made without a biopsy. However,
where sarcomas were first classified on the basis oping surgical expertise and the vastly improved some benign bone tumors can simulate a malig-
of their gross characteristics. Until orthopaedics staging and reconstructive techniques in the past nant process and is best handled by referral to a
emerged as a specialty, general surgeons who 30 years has led to the current preponderance physician trained in orthopaedic oncology for
usually treated tumors from all body systems treat- of limb-salvaging surgery and greatly improved additional evaluation.
ed patients with sarcomas. survival rates for patients with sarcomas.
Bone cancer is rare, with only about 1,900 cases
In the early 1970s, several dramatic changes in in the United States each year. In children and
diverse fields combined to revolutionize the surgi-
young adults, it usually strikes near the knee. Until
cal treatment of malignant bone tumors: (1) the
recently, these neoplasms were considered to have
development of chemotherapy; (2) improvements
the worst possible prognosis with a minimal
in diagnostic radiographic techniques; (3)
opportunity for a successful outcome of treat-
advances in reconstructive surgery; (4) improve-
ment. Not long ago, the preferred treatment for
ments in orthopaedic oncologic surgical expertise;
and (5) the establishment of multidisciplinary patients with sarcomas was limb amputation,
oncologic referral centers. which was accompanied by high morbidity and
Later, surgeons inspired by the pioneering work of
Dallas Phemister and Howard Hatcher at the Today, following surgery and chemotherapy, 70%
University of Chicago began to explore limb of patients with sarcomas are cured. Most of these
salvaging resection, or preservation, in lieu of children are now treated with limb-sparing surgery
amputation. With the advent of limb salvage followed by reconstruction. Limb-salvaging tech-
and the advances in reconstructive skeletal niques used today include allografts (bone trans-
surgery, orthopaedic oncology emerged as a plant from a cadaver), autogenous grafts, joint
well-defined specialty. replacement (usually metal), or a combination of
The growth of this discipline is enhanced by the
development of orthopaedic oncology fellow- Clearly, the ideal material with which to replace
ships, orthopaedic oncology societies, and bone is bone itself, but the major problem now
federally funded regional cancer centers and mul- facing us is that there is an insufficient supply of
tidisciplinary teams to treat patients with sarco- natural bone to satisfy the clinical requirements.
mas. Today there are more than 100 trained Anteolateral view of the knee where the bones that Hence, there is a need for the development of
orthopaedic oncologists performing more than comprise the hinge joint have been replaced with a chemically synthesized bone graft substitutes.
3,000 surgeries each year. Fellowship programs prosthetic knee Bone-replacement materials used successfully
add approximately 10 fellows per year.
More often than not, children diagnosed with a include porous biphasic ceramics, hydroxyapatite
Orthopaedic oncology is a subspecialty that bone tumor are the most common patients of the granules, and demineralized bone chips.
requires expertise in many areas of orthopaedics. orthopaedic oncologist. The diagnosis of a bone
On the horizon is a new type of degradable bio-
This includes joint reconstruction, pediatrics, trau- tumor in a child can be a source of great anxiety
material with bone-inducing capacity made by
ma and fracture care, foot and hand surgery, as for the patient, the parents, and the treating
combining porous beta-tricalcium phosphate
well as rehabilitation and amputee care. physician. Fortunately, most bone tumors in chil-
dren are benign. (beta-TCP) with a delivery system for recombinant
Wide-Ranging Field human bone morphogenetic protein-2 (rhBMP-2).
When compared with other orthopaedic sub- Although there are a variety of benign bone Quick returns to high patient functionality
specialties, orthopaedic oncology is intellectually, tumors that affect skeletally immature patients, following the use of these new replacement
12 Orthopaedic Excellence
Chicago’s first bone-transplant program at Rush
Primary Bone Cancers and performing the first successful transplant of live
cartilage in Chicago.
Osteosarcoma. The most common type thigh (femur), or shin (tibia) bones, but it is
Dr. Gitelis’ activities outside the medical center
of bone cancer, osteosarcoma, is often also found in the soft tissues of the body. include directing the Bone and Tissue Bank of the
diagnosed in teenagers or young adults. Chondrosarcoma. In many cases, chon- Regional Organ Bank of Illinois (ROBI) and serving
Osteosarcomas can grow anywhere in the drosarcoma is diagnosed in middle-aged as a ROBI trustee. He is also past president of the
skeleton, but they are most common in Musculoskeletal Tumor Society.
adults. It is relatively rare — about as
the thigh bone (the femur) and shin bone common as Ewing’s sarcoma. The cancer
(the tibia). Dr. Gitelis served in the U.S. Navy and served active
produces cartilage (chondroid), which is a duty at the National Naval Medical Center in
Ewing’s sarcoma. Named after the shiny, smooth substance that normally Bethesda, Maryland, during operations Desert
surgeon who first described it, Ewing’s covers the ends of bones in the joints. Shield/Desert Storm in 1990 to 1991. He received a
sarcoma, is also a bone cancer frequently Chondrosarcoma can grow inside a bone Navy Commendation medal in 1993. A Diplomate
diagnosed in teenagers and young adults. or on the bone surface, so islands of car- of the American Board of Orthopaedic Surgery
(99th percentile), Dr. Gitelis has presented
But unlike osteosarcoma, Ewing’s sarco- tilage can be found inside the bone or on
extensively and has been published nationally
ma is found in children and older adults as the surface in an area where it wouldn’t and internationally.
well. Ewing’s generally starts in the pelvis, normally grow.
Walter Virkus, MD, is an orthopaedic
materials suggest that bone graft substitutes are a limb reconstruction, and care for limbs at risk
surgeon with a unique combination of
reasonable alternative to autogenous grafting. for amputation. training in both orthopaedic trauma and
Limb Preservation Our practice (90% to 95% of our cases) is focused orthopaedic oncology. After receiving
on reconstructive surgery leading to limb salvation his doctorate from the University of
One of the major dilemmas in limb preservation in
Medicine and Dentistry of New Jersey and
skeletally immature and growing children involves and maintenance of full patient functionality. The
completing his internship at Mount Sinai Medical
the ability to maintain leg length equality. importance of this approach is obvious when
Center in New York City, New York, Dr. Virkus went
Previously, every six to eight months additional we realize that the patients are mostly children
on to complete his orthopaedic residency at the
surgery was necessary to accommodate the and adolescents.
University of Maryland. He received his training in
lengthening limb. The Phenix® (also known as orthopaedic trauma through fellowships at the
There are few centers that do this type of
Repiphysis), a noninvasive, expandable prosthesis Shock Trauma Center in Baltimore, Maryland, and
orthopaedic oncology and joint reconstruction
for skeletally immature children after limb salvage the Hospital for Special Surgery in New York City,
surgery on children. At Rush, from surgery
surgery, was developed specifically to address New York. He completed a fellowship in orthopaedic
through rehabilitative care, the focus of the col-
this issue. oncology at the University of Florida in Gainesville.
laborative effort of our team is on optimizing
The Phenix technology has been used in France for outcomes for these complex cases. Dr. Virkus is currently an Assistant Professor of
several years. The device is composed of titanium Orthopaedic Surgery at Rush Medical College,
and polyether ketone plastic and weighs about Assistant Attending Physician of Orthopaedic
the same as the patient’s normal bone. It varies in
Steven Gitelis, MD, is a highly regard- Surgery at Rush University Medical Center, and a
length between 8 and 10 inches at the time it is
ed expert in the area of orthopaedic member of the medical team for the Rush Center
surgically implanted. It is designed to lengthen up oncology and joint replacement. He is a for Limb Preservation. The majority of his practice,
to 3 inches. pioneer in limb-sparing surgical proce- which focuses on orthopaedic trauma and oncolo-
The basic principle involves energy storage in a dures. Having obtained his early gy, is at Rush University Medical Center. Dr. Virkus
orthopaedic oncology experience during fellow- is also the Senior Attending Orthopaedic Surgeon
spring, which is maintained compressed by a lock-
ships at the respected Rizzoli Institute in Bologna, on the staff of Cook County Hospital in Chicago,
ing system. When the device is exposed to electro-
Italy, (under Professor Marion Campanacci) and at Illinois, one of the busiest Level 1 trauma centers in
magnetic waves, the plastic momentarily melts,
the Mayo Clinic in Rochester, Minnesota, Dr. Gitelis the nation, where he also treats cancer patients.
allowing the titanium spring to expand. When the
currently serves as the Director of the section of
device is no longer exposed to electromagnetic orthopaedic oncology, an Associate Chairman of Dr. Virkus has special interests in extremity and
waves, the plastic returns to a solid state. Each the Department of Orthopaedic Surgery at Rush pelvic fractures as well as reconstruction, non-
lengthening takes less than 10 seconds and occurs University Medical Center, and Director of the unions, complex limb reconstruction, minimally
as necessary throughout the child’s life. Rush Center for Limb Preservation. invasive fracture surgery, and bone-transplant
surgery. His research interests include fracture fixa-
The Center for Limb Preservation at Rush Dr. Gitelis also maintains a practice at Rush with an tion, bone-graft substitutes, and limb-reconstruc-
University Medical Center, the only program of its emphasis on orthopaedic oncology and joint recon- tion methods. Dr. Virkus has authored numerous
kind in the Midwest, is dedicated to preserving struction. Specialty areas include pediatric cancer articles and chapters on both trauma and oncology.
limbs in individuals with a risk of significant func- surgery, growing prostheses, and minimally invasive He is on the faculty of AO North America
tional loss. The preservation program includes bone grafts with an emphasis on limb salvage and and is a Fellow of the American Academy of
treatment for complex skeletal injuries, complex chondrosarcoma. He is also known for establishing Orthopaedic Surgeons.
Orthopaedic Excellence 13
Best in Class
Rush Orthopaedics Ranks #1 in Illinois
By Zachary Settle
he Rush University Medical Center cartilage restoration, arthroscopic knee and shoul- Bush-Joseph, MD, Managing Partner of Midwest
Orthopaedic Program was ranked among the der repair, cartilage transplantation, as well as Orthopaedics at Rush.
best in the nation by U.S. News & World minimally invasive spine surgery.
“We feel that this dedication to comprehensive
Report magazine in its 2005 “America’s Best
Hospitals” special issue. The magazine chose only “Our physicians are highly regarded within the orthopaedic care has greatly contributed to the
167 hospitals from more than 6,000 across the medical community as we continue to maintain a number-one ranking we received.”
nation and evaluated the top 50 hospitals for each leadership position in terms of the orthopaedic
of 17 categories, including orthopaedics. advancements we have pioneered,” says Charles
Orthopaedic programs were evaluated based on
several requirements, including reputation, mor-
tality ratio, discharges in the past three years,
nurse-to-patient index, nurse magnet facility
status, four key technologies, seven patient or
community services, and trauma services. Rush
scored well or perfect in all categories, earning the
orthopaedic program a designation of eighth best
in the United States, up two spots from last year,
and first in Illinois.
at Rush (MOR) is
recognized as the Midwest
region’s top leader in
U.S. News & World Report referred to the best
hospitals as an “elite group” due to the great
number of procedures performed, the constant
advancements in devices and technologies, and
the pioneering of new treatment guidelines.
Midwest Orthopaedics at Rush (MOR) is recog-
nized as the Midwest region’s top leader in
orthopaedic services. Midwest Orthopaedics
physicians are specially trained in orthopaedics
and its subspecialty areas to diagnose and treat
the most complicated and rare conditions.
MOR combines education and research with its
clinical practice to generate the best outcomes Chicago • Oak Park • Winfield
possible and to treat the most difficult conditions. 877-MD-BONES
MOR has pioneered numerous advancements,
including minimally invasive joint replacements,
spine fusions, ACL and rotator cuff repairs,
14 Orthopaedic Excellence
Orthopaedic Excellence 15
Motion-Sparing Spine Technology
Examining Disc Replacement and Low Back Pain
By Kern Singh, MD
ack pain is the most common ailment of the serve as shock absorbers and areas of motion. The When surgery is used to treat degenerative discs,
working-age adult, affecting more than four disc is a tough but pliable tissue that helps main- the surgical treatment of choice has traditionally
million individuals each year in the United tain the position of the spine but also allows consisted of a lumbar spinal fusion. Unfortunately,
States and weighing an economic burden on our motion between the vertebrae. With this design, fusion surgery is not without complications. First,
health care system at up to $100 billion. we have the stability to stand upright but also the the ability of the bone to heal or “fuse” varies.
Approximately 80 percent of Americans experi- flexibility to bend and twist. The average success rate of a lumbar spinal fusion
ence significant back pain at least once in their is approximately 75% to 80%.
lifetimes, and for many people, spinal disorders As a natural part of aging, discs deteriorate.
are a lifelong problem. While most acute episodes Unfortunately, pain may occur as the disc wears Failure of the fusion to heal is sometimes associat-
of low back pain are self-limiting and respond well away. When the disc degenerates, it becomes ed with continued symptoms. Second, a spinal
to nonoperative therapies, the management of more brittle and less flexible; and thus the disc fusion at one or more levels will cause stiffness
chronic low back pain remains a difficult challenge becomes more prone to injury. As a result, the disc and decreased motion of the spine. Third, having
for the nonoperative and operative physician. loses its shock-absorbing properties. Exactly what a spinal fusion at one or more levels will cause
causes pain with lumbar disc degeneration is more stress to transfer to adjacent levels, which
One cause of back pain is spinal disc degenera- unknown, but we do know that some patients will then have to work harder to compensate for
tion. Disc degeneration can be painful and is often with worn-out discs have symptoms of low back the loss of motion. The problem with the trans-
difficult to treat. A promising new surgical option pain (Figure 2). ferred stress is that it may cause new problems to
for the management of discogenic pain is the arti- develop at the other levels, which may also lead to
ficial disc replacement. additional back surgery.
What Is a Spinal Disc? Treatment Diversity
The spinal column is made of stacked bones called The diversity of approaches and the variation
vertebrae. These bones are separated by a cushion observed in treatment strategies for low back pain
at each level called a spinal disc. The spaces indicates an absence of evidence-based support
between each vertebra in the spine (spinal discs) for any single method. While the rate of back sur-
geries including fusion of the spine has increased
by more than 600% between the years 1979 and
Figure 2: Posterior rupture of the inner portion of the 1990, there remains no operative treatment that
intervertebral disc results in pressure on the nerve root.
has yielded reliable and reproducible positive
Traditional Surgical Management results in patients affected by chronic low back
pain. The common denominator is that few cur-
There are multiple conservative and minimally
rent techniques provide restoration of normal
invasive treatment options available to manage
structure and function of the affected spinal
moderately symptomatic degenerative disc dis-
ease. For those with severe symptoms not
responding to nonoperative measures, there are Indications for Disc Replacement
several surgical techniques available: Intervertebral disc replacement is indicated for
patients with degenerative disc disease at one or
• Intervertebral disc excision (discectomy) for
two levels of the spine. In order to avoid complica-
the treatment of herniated discs (Figure 1)
tions that may arise from artificial disc replace-
• Intradiscal procedures including injections ment surgery, careful patient selection by the
(epidurals), electrothermal exposure (IDET), surgeon is critical.
and implantable neural stimulators and
medication dispensers (spinal pumps) Based on the current research, the clinical diag-
noses that seem the most fitting for artificial disc
• Arthrodesis (fusion) of the spine using pos- replacement include symptomatic degenerative
terior (from the back), anterior (from the disc disease and postdiscectomy syndrome.
Figure 1: Excision of an intervertebral disc during discectomy front), or combined approaches. Postdiscectomy syndrome is persistent back pain
16 Orthopaedic Excellence
following a previous surgery to remove a herniat- medical history and medical options thoroughly inserted in the space between the vertebrae and
ed disc. Patients are candidates for artificial disc with the treating spine surgeon before deciding attached to the vertebrae above and below the
replacement if they meet the following conditions: on the surgery. disc. A polyethylene material is then inserted
between the plates to create a disc-like structure
• Diagnosis of degenerative disc disease or Intervertebral Disc Design
that mimics the normal disc by providing a normal
postlaminectomy syndrome at either L4-L5 There are a variety of factors designers must keep level of separation between the vertebrae and by
or L5-S1 levels of the lumbar spine in mind as they develop an artificial disc. The allowing the usual range of motion and flexibility
device must be able to maintain proper interverte- for that segment of the spine (Figure 4).
• Patients who are between the ages of 18 bral spacing, allow for the full range of motion,
and 60 years old and provide stability. It must also come in a variety Theoretical
Advantages of Disc
of sizes to accommodate patient height and
• Patients who suffer from low back pain as Replacement
the major complaint (rather than leg pain) The CHARITÉ disc
Like a natural disc, the artificial disc must act as a implant is designed to
• Patients who have not responded to a min-
shock absorber, especially if it is used in several mimic the functionali-
imum of six months of conservative treat-
levels of the spine at one time. Finally, the artificial ty of the patient’s
ments (nonsurgical care such as physical
disc must be very durable. The average age of a own intervertebral
therapy, pain medications, etc.)
patient needing a lumbar disc replacement is disc. The prosthesis is
• Patients who are candidates for spine sur- about 35 years. intended to maintain
gery (such as a lumbar fusion) the normal move-
This means that to avoid revision surgery, the arti- Figure 4: Diagram of disc in ment between the
• Patients who have only one level disc dis- ficial disc must last at least 50 years. It is estimat- the spine vertebral bodies and
ease (either bottom disc level, L5-S1, or the ed that an individual takes two million steps per prevent them from collapsing (and thereby irritat-
second to the bottom, L4-L5) year and bends 25,000 times; therefore, over the ing or damaging the nerve root) by maintaining
50-year life expectancy of the artificial disc, there the disc space height between the bones.
Patients with the following diagnoses are not can- are more than 106 million cycles. This estimate
didates for disc replacement: does not even include the subtle disc motion that One of the main theoretical advantages of artifi-
occurs with breathing. cial discs (vs. spine fusion surgery) is to preserve
• Active infection the mobility of the patient’s adjacent discs and
The material from which an artificial disc is made delay the onset of arthritic changes adjacent to a
• Spinal stenosis is also an important factor in the development of fused level. The procedure may substitute spinal
this technology. It requires materials that are safe fusion, which eliminates the motion from a painful
• Spondylolisthesis (or other types of instabil-
for human body implantation. motion segment by fusing the vertebrae together.
ity in the spine, such as a fracture or
tumor). Patients who have only minor slip- It must not cause allergic reactions, and it must Spinal fusion does tend to place increased stress
page of the vertebrae (0.3 mm or less) may not damage other parts of the spine. Also, it is on the adjacent vertebral segments (Figure 5).
still be candidates. ideal if the artificial disc is made of a material that
is easily seen on an x-ray or other imaging test.
• Scoliosis This makes it easier for the surgeon to monitor the
• Posterior facet joint disease (i.e., facet joint effectiveness of the artificial disc over time.
• Significant radiculopathy (pain radiating
down the leg)
• Osteoporosis or poor bone quality
Figure 5: A postoperative lateral radiograph of a patient
Other factors in selecting candidates for disc with an L5-S1 disc replacement
implant may apply in certain circumstances. For
instance, the surgeon may recommend against the Figure 3: CHARITÉTM disc replacement (DePuy Spine, Inc.) Potential Disc Replacement Drawbacks
procedure if the patient is morbidly obese, has spe- In addition to the potential complications associat-
cific allergies, or has another medical condition. ed with undergoing surgery and general anesthe-
The CHARITÉTM Artificial Disc (DePuy Spine, Inc., a sia, the complications associated with artificial disc
Certain psychological and emotional factors and Johnson & Johnson company), (Figure 3), is com- replacement may include breakage of the metal
other circumstances may also at times play a fac- posed of two metallic endplates and a polyethyl- plate, dislocation of the implant, and infection.
tor in deciding who may potentially benefit ene core that moves between them. During the
from the disc replacement surgery. Therefore, it is surgery, the degenerated disc is removed and a To help minimize complications associated with
best for the patient to fully discuss his or her pair of endplates made of cobalt chromium are the implant itself, proper selection of patients >>
Orthopaedic Excellence 17
and implant size are very important. Otherwise, extension, side bending, and rotation) can closely replacement using the CHARITÉ artificial disc
patients may not improve following the procedure approximate the normal motion of a healthy disc. allows natural motion in the part of the spine
and may require additional surgery. where the disc is implanted. This is because the
Postoperative Course prosthesis is designed to imitate normal move-
Finally, like joint replacement surgery, artificial Most patients spend one or two nights in the hos- ment between adjacent vertebrae.
implants may fail over time due to wear of the pital. Patients may require an extra day or two if
materials and loosening of the implants. for some reason they are having extra pain or A successful result means that back symptoms are
Therefore, long-term studies that track the life unexpected difficulty. Patients generally recover better but not necessarily perfect. Most studies
span of the implants are needed. quickly after the artificial disc procedure. show that 70% to 90% of patients have signifi-
cantly less back pain and greatly improved func-
Artificial Disc Surgery Patients should be able to get out of bed and walk tion with the operation. More than 70% are able
The goal of the lumbar artificial disc procedure within a few hours. Patients can move carefully to discontinue the use of strong medications.
is to restore the intervertebral disc height and and comfortably and must remember to avoid
neuroforaminal height while restoring physio- extending their backs (bending backward). Recent studies show greater satisfaction among
logic motion (similar to that of a healthy disc) in Patients may need to wear a corset-type brace or people who have had disc replacement surgery
compared with those treated with lumbar fusion.
While still in its infancy, artificial disc replacement
A successful result means that back symptoms are better offers an alternative solution to the difficult prob-
lem of chronic discogenic pain.
but not necessarily perfect. Most studies show that 70% to
90% of patients have significantly less back pain and
greatly improved function with the operation. Kern Singh, MD, received his medical
degree from Jefferson Medical College.
Dr. Singh completed his orthopaedic
that segment of the spine. The surgery re- elastic bandage for up to two weeks following the residency at Rush-Presbyterian-St.
quires complete removal of the unhealthy disc in surgery to support the abdominal muscles after Luke’s Medical Center. He completed a
order to implant the new artificial disc. Surgery the operation. fellowship in spinal surgery at Emory University in
details include: Atlanta, Georgia. Dr. Singh will join the team of
As patients recover in the hospital, a physical physicians at Midwest Orthopaedics at Rush in
• The CHARITÉ artificial disc surgery is therapist will visit to start him or her on a few September 2005. He specializes in treating complex
approached from the front, with a relative- gentle exercises. The patient will also start a walk- degenerative disorders of the cervical, thoracic, and
ly small incision in the abdomen (usually ing program that is encouraged following the lumbar spine and has a particular interest in mini-
below the belly button). hospital stay. mally invasive, motion-sparing spinal technology.
When leaving the hospital, patients are usually
• The abdominal organs are then gently
safe to sit, walk, drive, and ride a bike. The
moved to the side so that the surgeon can
surgeon will see the patient a week later to take
visualize the spine while protecting impor-
an x-ray, ensuring the prosthesis is in place and
tant anatomic structures. A general sur-
geon or vascular surgeon with the appro-
priate skills usually does this part of However, patients should avoid lifting items for at
the surgery. least four weeks. The surgeon will approve a
release back to work in three to four weeks as
• The spine surgeon then removes the col- long as the work is fairly light. If the job requires
lapsed, degenerated disc. moving and lifting heavy items, a longer period
of recovery is required. The surgeon may give
• The artificial disc is then implanted — first
the OK to do all activities by the eighth week
the two endplates, then the core in the
middle — using specialized instruments.
The two endplates (made of a cobalt Initial experience with composite prostheses in
chromium alloy) are pressed into the verte- Europe suggests safety and efficacy of these
brae above and below the disc space, and devices. Prospective randomized studies compared
teeth along the border of the endplate grip with traditional fusions will offer an evidence basis
the vertebral bone. A polyethylene core is for the role of disc replacement in the current and
then placed between the endplates. future management of degenerative disc disease.
Artificial disc replacement offers an alternative to
The artificial disc is held in place by the spinal lig- lumbar fusion for some patients who have chron-
aments and the remaining part of the anulus of ic low back pain from degenerative disc disease.
the disc as well as the compressive force of the
spine. Bending x-rays of patients after the surgery While fusion stops pain by eliminating move-
show that the motion of the artificial disc (flexion, ment in the problem spinal segment, artificial disc
18 Orthopaedic Excellence
Orthopaedic Excellence 19
Total Hip Arthroplasty Using Porous-Coated
Long-Term Studies Demonstrate Effectiveness
By Craig J. Della Valle, MD
ngoing studies of total hip arthroplasty at reconstruction in primary total hip arthroplasty. 1980s in an effort to improve upon the results
Rush University Medical Center have demon- While these components were used extensively in obtained with cemented acetabular components.
strated an impressive component survival the past, since their introduction in the 1980s, The original technique for total hip arthro-
rate. In a cohort of 184 patients who underwent there has been a paucity of long-term data to plasty included the use of a metal stem and a
204 cementless primary total hip arthroplasties support their use. plastic cup that were both inserted with bone
using porous-coated acetabular implant devices, cement. Although these earlier components pro-
the 15-year component survival rate was 99%. Originally designed at Rush University Medical vided good initial results, longer-term studies
Accordingly, this approach has become the Center with Dr. Galante’s assistance, the acetabu- identified increased rates of radiographic and
standard of care at Rush University Medical Center lar metal shell is made of commercially pure clinical loosening.
and in centers around the world for acetabular titanium. It is hemispherical and fully coated
In addition, the surgical technique for a cemented,
with sintered titanium
all-polyethylene cup technique was demanding,
fiber metal mesh. As
with difficulties encountered in routinely
obtaining a bloodless field and achieving
and by four orthopae-
optimal cement pressurization, even in the hands
dists at our institution,
of experienced surgeons.
the surgical technique
includes reaming the To overcome these challenges, a number of novel
acetabulum with hemi- designs were implemented, including threaded
spherical reamers and components and hemispherical designs. A variety
using screws for of strategies to achieve initial implant stability
adjunctive fixation. were used such as dome and peripheral screws,
peripheral threads, dome spikes, peripheral fins,
In this very young
and insertion with a press-fit technique in which
the component was slightly oversized compared
(average age 52 years
with the diameter of the prepared acetabulum.
old), the failure rate was
very low with only 7% These components rapidly became the most pop-
of patients requiring a ular type of acetabular implant design because the
reoperation for wear of surgical technique was simpler than cement fixa-
the plastic liner and only tion, and the theoretical advantages of biological
one acetabular compo- fixation (growth of bone into the components)
nent revised for loosen- and modularity (the ability to change the plastic
ing. These patients also liner without removing the metal shell) were seen
had impressive clinical as attractive. However, new difficulties arose with
scores, with 94% of increased rates of polyethylene (plastic) wear and
patients having hip osteolysis (bone loss related to inflammation
scores considered good caused by wear particles generated at the bearing
or excellent. surfaces) reported as common complications of
Origin of Cementless cementless reconstruction.
Components Cemented vs. Cementless Designs
During the last 20 years, attributes of the
c o m p o n e n t s w e re
Anterior view of pelvic skeleton where the bones comprising the ball and socket joint of more successful designs have been incorporated
introduced in the early
the hip were replaced with a prosthetic hip into the most modern cementless acetabular
20 Orthopaedic Excellence
components, such as those utilized in the studies Importance of Surface Coatings HA has also been used in combination with
at Rush University Medical Center. Tougher Most modern hip replacement component tricalcium phosphate (HA-TCP) in an effort to
bearing surfaces were developed, including designs include an ingrowth or ongrowth surface promote bone ingrowth on metallic surfaces. One
highly crosslinked, ultrahigh molecular weight for bone fixation. A critical factor in this design is clinical trial that compared a titanium fiber metal
polyethylene and ceramic-on-ceramic and metal- pore size, optimally in the 100 to 400 micrometer mesh component with and without HA-TCP
on-metal couples. coating demonstrated no clear clinical benefits to
range for osseointegration. The most common
Numerous studies of cementless acetabular recon- surface coatings are sintered titanium fiber metal
struction with follow-up of more than 10 years mesh and cobalt chromium beads. Titanium fiber Current Standards of Practice
show that the majority of these implants are metal mesh was used in one of the earliest designs Based on the results of our studies, we continue to
associated with acceptable rates of implant and continues to demonstrate excellent, long- use a cementless, porous-coated acetabular com-
stability. This demonstrates an improvement over term success with implant fixation. ponent with fiber metal mesh for the majority of
rates of successful fixation using components Some acetabular component designs have incor- primary total hip arthroplasties performed at Rush
inserted with cement. University Medical Center. Although some good
porated the use of a hydroxyapatite (HA) coating
results have been reported after arthroplasties in
Some early attempts to implant cementless which a cementless acetabular metal shell was
acetabular components made of nonmetallic inserted with a press-fit technique without screws,
materials, however, demonstrated unacceptable
rates of failure and were abandoned. The primary
OrthoFact we continue to use screws in the majority of
reconstructions in addition to obtaining a press fit
Hip fractures are caused by a variety of
implant materials used today are titanium and of the component by under-reaming the acetabu-
factors that weaken bone and are often
cobalt chromium alloys. Autopsy retrieval studies caused by the impact from a fall. The common lum by 1 or 2 mm.
and animal models have demonstrated that characteristics of persons who are vulnerable
although both materials are biocompatible and The increased number of reoperations because
to hip fractures are: of liner wear and the increased presence of
support bone ingrowth, titanium implants have
been associated with higher amounts of bone osteolysis necessitate close radiographic monitor-
ingrowth. Additionally, the quality of bone • Age. The rate increases for people 65 and ing of all patients who have undergone a total hip
older. arthroplasty because liner wear and osteolysis are
formed around both kinds of implants appears to
• Gender. Women have two to three times as often asymptomatic.
be the same.
many hip fractures as men.
In our study, follow-up of patients at both 15 years
Theoretically, if a press-fit technique is used, the • Heredity. A family history of fractures in and 18 years revealed that the most common rea-
lower modulus of elasticity of titanium may pro- later life, particularly in Caucasians and sons for additional revision surgery were related to
duce less stress remodeling of the host pelvic bone Asians. A small-boned, slender body. wear of the plastic liner. We now routinely use a
and a more flexible implant, leading to greater • Nutrition. A low calcium dietary intake or plastic liner that has shown in both hip simulator
ease of insertion. In addition, there is a potential reduced ability to absorb calcium. and clinical studies to be more wear resistant than
for a lower risk of insertional fracture. Moreover,
• Personal habits. Smoking or excessive prior formulations in the hopes of further improv-
titanium is an easier metal to manufacture and alcohol use. ing upon the results previously described.
less expensive than some other materials.
• Physical impairments. Physical frailty, arthri-
We continue to follow this cohort to ensure
One of the newer implant materials used in tis, unsteady balance, and poor eyesight.
the long-term results of the procedure and to
cementless acetabular components is tantalum, or • Mental impairments. Senility and dementia engage in ongoing research for further refine-
“trabecular metal.” Tantalum is an elemental (e.g., Alzheimer’s disease). ments and improvements to aid both physicians
metal with a highly porous structure, an elastic • Weakness or dizziness. These are often the and patients worldwide.
modulus closer to bone than chromium or titani- side effects of medication.
um, a high coefficient of friction that helps initial Craig J. Della Valle, MD, received his
implant stability, and a biocompatibility that pro- medical degree from University of
motes bony ingrowth and soft-tissue attachment. Pennsylvania. Dr. Della Valle completed
to improve bony ingrowth or ongrowth. HA is an his residency at the Hospital for Joint
Autopsy retrieval studies of various component osteoconductive material that has been shown in Diseases in New York City, New York. He
designs show that bony ingrowth into clinically animal models to optimize bony attachment to fix- completed a fellowship in adult reconstructive sur-
successful cementless acetabular components gery at Rush University Medical Center and Central
ation surfaces. Fixation theoretically would be
ranges from none to more than 80%, with an DuPage Hospital. Dr. Della Valle specializes in lower
achieved as the surrounding bony surface bonded
average of 15% to 30%. Areas of maximal bony extremity total joint arthroplasty, and he has a keen
to the HA coating, which is bonded to the acetab- interest in minimally invasive surgical techniques
ingrowth tend to be in the area of fixation screws, ular cup. Early designs were smooth, hemispheri- and complex primary and revision surgery.
spikes, or pegs. These studies have confirmed that cal components that relied on a press fit to obtain
screws are more effective than spikes in augment- initial stability without screws for fixation.
ing bony ingrowth, which may be related to both
increased stability and greater apposition to host But those components have demonstrated poor
bone because screws tend to draw the metallic intermediate-term results because the HA coating
surface closer to the bony bed. was resorbed, which led to aseptic loosening.
Orthopaedic Excellence 21
Microprocessor Prosthetic Knee
A Step Forward at Rush:
The First Hip Disarticulation C-Leg Prosthesis
By James A. Kaiser, BS, CP/L
patient returning from World War II 60 years right femoral fracture requiring a femoral rod, but
ago with a high-level, hip disarticulation the cancer was considered in remission at the
amputation most likely faced a life without a time. CD was followed at the children’s hospital
limb. At the time, the prosthetic technology con- until he reached the age of 18 years. Married in
sisted of heavy wooden prosthetic knees and feet 2002, CD is now a successful, self-employed floor-
as well as leather sockets with suspenders and ing specialist. But, after nearly 18 years in remis-
straps. The prosthesis was seldom used because sion, CD was recently diagnosed with a hystocy-
ambulation required excessive energy. toma carcinoma of the distal right femur.
Today, the men and women returning from the Due to the limited strength and musculature of the
war in Iraq who have sustained explosion injuries right femur, Walter Virkus, MD, at Rush performed
are faced with the same diagnosis. But today’s a complete hip disarticulation amputation in
advanced prosthetic technology provides them September 2004. Following surgery, chemothera-
with a prosthetic limb that is functional, enabling py treatment was initiated. In October 2004, phys-
them to feel whole again. ical therapy was initiated, and in November 2004,
a prosthetic prescription was provided.
The development of lightweight, external pros-
thetic components and joints made from titanium In formulating the initial prescription, Scheck and
reduces the weight of the prosthesis. Additionally, Siress Prosthetics, Inc., teamed with the Rush
functional, alignable, and dynamic prosthetic feet Orthopaedic and Rehabilitation staff to design a
enable the patient to accommodate various heel lightweight, functional hip disarticulation (HD)
heights by simply changing shoes, without the prosthesis — the first of its kind at Rush.
fear of creating knee instability. A torque absorber “It is a blessing to have a prosthesis that function-
Advanced Prosthetic Technology ally enables me to walk without the assistance of
in the shin component minimizes rotation forces
during gait. The microprocessor knee component The “prescription” included a right endoskeletal a crutch or cane. It is a tremendous mental boost
responds 50 times per second to spacial and HD prosthesis with an inner, flexible proflex sock- to feel whole again with my prosthesis,” CD says.
ground reaction forces to control the knee in both et liner and copolymer frame, an Otto Bock 7E7 The team approach of Rush and Scheck and Siress
swing and stance phases of gait. A thigh turntable external hip joint with HFB system, a thigh posi- Prosthetics, Inc., has made all the difference in his
component above the knee allows for positioning tional turntable, an Otto Bock microprocessor- life, he says. The nearby outpatient prosthetic care
of the shin in abducted or adducted positions controlled knee component, a shin rotational unit, and his visit to Rush for therapy treatments have
while sitting. and an Elation dynamic response single-axis foot enabled him to take that step forward with the
with an adjustable heel-height component. completion of his chemotherapy in May 2005.
The external standard prosthetic hip joint is
becoming dynamic with the addition of a hip-flex- In January 2005, CD received the trial prosthesis
ion bias (HFB) system currently under development with a mechanical, four-bar knee to begin gait
at Scheck and Siress Prosthetics, Inc. The socket is training. He progressed rapidly from the parallel James A. Kaiser, BS, CP/L, graduated from
fabricated with flexible copolymers that accom- bars to two crutches to a single crutch, then to a University of Illinois and Northwestern University
modate the skeletal anatomy, offering function single cane and near independent ambulation with a prosthetic education certificate and has
and comfort. within six weeks. The HFB system offered hip-flex- worked in prosthetics for the past 31 years. He has
ion assistance and stride-length control in the early been CEO of Scheck and Siress Prosthetics, Inc., for
Surgical Planning and Chemotherapy stages of training. The final HD prosthesis with the 22 years. Kaiser left Rush in 1974 as a research
CD was an active, 11-year-old male diagnosed Otto Bock C-leg microprocessor knee was provid- lab tech to accept a position with Scheck and Siress.
with Ewing’s sarcoma at the right mid-femoral ed in April 2005. With additional C-leg training, Kaiser is on the staff of the Northwestern University
level in 1984. He was treated at a children’s hospi- CD is now actively ambulating independently, with prosthetic education department. He primarily
tal with chemotherapy for a year and a half and increased ease, security, and functional control sees patients with high-level, lower extremity
radiation for six months. In 1988, he incurred a during both swing and stance phase of gait. prosthetic needs.
22 Orthopaedic Excellence
Orthopaedic Excellence 23
Ergonomics Protocol Basic Ergonomic Principles
for Office Video-Display
When It’s Time to See a Specialist Adjust your seat so when in typing posi-
tion, your arms hang freely from your
By Beth Healy, CRC/R, CEAS shoulders and your forearms are in a
would like to see more patients benefiting in body mechanics, safe work methods, and
from the work of certified ergonomics assess- stretching exercises; and make recommendations For many people, finding the correct
ment specialists (CEASs), physical therapists for adaptive equipment. They also conduct typing height means their feet are no
(PTs), and occupational therapists (OTs) who ergonomic job analyses, which quantify the phys- longer firmly on the floor. If that is the
specialize in ergonomics in order to attack the ical demands of a patient’s job to assist physicians case, a foot support such as a box,
workers’ compensation dilemma where it and employers in determining if the patient is able book, or footrest can be used. Not sup-
begins, namely the workplace. to return to work. porting your legs and feet can lead to
circulation problems or back pain.
Diagnosing and treating the patient is only Since the early 1980s,
half of the equation. We need to look at and Keep wrists in a neutral position,
address the work site as well. Ergonomics, or
a rapid increase in MSDs has
straight in line with the forearm. They
work-site consultations, are one of the most been reported, with costs to should not bend up or down. Use a wrist
effective but often underutilized return-to- employers estimated at rest if necessary.
$132 billion annually. Organize your work in a manner that
Since the early 1980s, a rapid increase in the allows your head to be straight in line
incidence of musculoskeletal disorders (MSD) Accelerated Rehabilitation Centers has more than
with your body most of the time. Place
has been reported, with costs to employers esti- 20 PTs and OTs with CEAS certification through-
materials within easy reach.
mated at $132 billion annually. This increase has out Illinois, Arizona, Georgia, Indiana, Michigan,
created a growing demand for ergonomic pro- and Iowa. The top of your screen should be
grams to assist employers in creating safer work at or slightly below eye level. The
These therapists can help control the costs of
environments and reducing costs associated screen should swivel horizontally and
with these disorders. tilt vertically.
• helping employers identify risk factors and
MSDs in the workplace are caused by exposure to Use a document holder if significant
hazards in the workplace that contribute
the following key risk factors: repetition, force, typing from documents is required.
awkward postures, contact stress, and vibration. Position the document holder so that it
In 1994, the Bureau of Labor Statistics reported • designing ergonomic and injury-prevention is directly beside the screen and the
that for cases involving lost workdays, approxi- programs to help reduce the number and same distance from your eyes as the
mately 705,800 cases (32%) were the result of severity of MSDs. screen, so your eyes can remain focused
overexertion or repetitive motion, including as they look from one to the other.
• providing employers with a detailed written
• 367,424 injuries due to overexertion in report of risks and recommendations. Put your buttocks in the back of the
lifting (65% affected the back), chair, fully using its back/lumbar sup-
• assisting employers in designing and im-
port. Keep your head back over your
• 93,325 injuries due to pushing or pulling plementing on-site stretching and
strengthening exercise programs to help shoulders; concentrate on not leaning
objects (52% affected the back),
control MSDs. your head forward or hunching over.
• 68,992 injuries due to overexertion in Avoid glare by positioning your screen
holding, carrying, or turning objects • conducting workstation evaluations and
ergonomic job analyses following work- away from light sources. Focus into the
(52% affected the back),
related injuries or nonoccupational illnesses distance periodically. Keep your screen
• 47,861 disorders affecting the shoulder to assist in determining job modifications clean. Use a glare-reducing screen if
(totaled across all three categories), and that will allow for safe and successful necessary.
returns to work.
• 92,576 injuries or illnesses due to repeti- Take frequent stretch breaks. Vary your
tive motion (55% affected the wrists). Beth Healy, CRC/R, CEAS, is Vice President of tasks so that you are not sitting for
Marketing/Occupational Health with Accelerated extended periods of time.
CEASs evaluate patients in relation to their work Rehabilitation Centers in Chicago. For more infor-
environments. They analyze work methods, mation, you can reach her at (877) 977-3422 or
layouts, tools, and equipment; instruct patients visit www.acceleratedrehab.com.
24 Orthopaedic Excellence
Orthopaedic Excellence 25
Big Plans for Pediatric Orthopaedics and Midwest Orthopaedics at Rush
e are sad to announce that our pediatric and we keep our eyes open for a pediatric other pediatric orthopaedic surgeons operating in
orthopaedic surgeon, Jeffrey Sawyer, MD, orthopaedic subspecialist who can provide the the Chicago area that we can and will tap as
left Midwest Orthopaedics at Rush (MOR) patient-centered service we have provided for the needed. In any regard, we will keep you informed
at the end of May 2005. (See Dr. Sawyer’s last five years. We also developed a network of of how we plan to move forward.
letter in inset for more specific details about his
new opportunity and where he is now.) Dr. Sawyer
provided a tremendous service to the patients
of MOR and especially the children who were
the focus of his practice. (See related story on February 28, 2005
page 27 on Haitian patient with clubfoot.) He will
be sorely missed. Dear Colleagues:
What is the plan for MOR’s Pediatric Orthopaedic I am writing to you today with mixed in mid-July at the Campbell Clinic/LeBonheur
Program? As you may know, it is very difficult to emotions. Over the past months, I Children’s Hospital in Memphis, Tennessee.
find or recruit a pediatric orthopaedic surgeon have been approached by several
these days, and there are only a handful coming children’s hospitals across the coun- For patients who need ongoing care, I have
try to join them. After long and care- arranged for the following highly qualified
out of the few fellowship programs that are still
ful consideration, I have accepted a position physicians to assume the orthopaedic care of
with LeBonheur Children’s Hospital and St. our patients. I admire these physicians both for
As a result, we have decided to address this need Jude’s Medical Center in Memphis, Tennessee. their personal and professional qualities.
with a combination of working with some old
LeBonheur Children’s Hospital, which is the Howard An, MD
friends and colleagues, as well as utilizing our exist-
referral center for a 400-mile area between St. Pediatric Spine
ing physicians and resources within MOR to contin-
Louis, Nashville, New Orleans, and Dallas, is (312) 432-2300
ue to provide coverage for our pediatric patients.
undergoing expansion as well as building an Midwest Orthopaedics at Rush
We are working closely with our longtime col- entirely new pediatric hospital. I have been
John Lubicky, MD
leagues at Rush, Orthopaedics and Scoliosis, LLC. asked to head up a new section on pediatric
More specifically, Orthopaedics and Scoliosis limb deformity there as well as become involved
recently welcomed John Lubicky, MD, who is a in the development of the pediatric orthopaedic
Orthopaedics and Scoliosis Fractures & Spine
nationally renowned pediatric orthopaedic sur- program at the new hospital. It is an honor they
geon specializing in spinal deformities. considered and eventually offered me this Nikhil Verma, MD
tremendous opportunity and responsibility. It is Adolescent Sports Medicine
Dr. Lubicky is also Professor of Orthopaedic Surgery one I look forward to with great enthusiasm. (312) 432-2300
at Rush Medical College and holds the Ronald L. Midwest Orthopaedics at Rush
DeWald, MD, Chair of Spinal Deformity at Rush. This decision comes with some degree of sad-
Dr. Lubicky will work in our offices one day per ness. The most difficult aspect of this decision I would like to thank you all for the opportuni-
week, seeing most of the children that would have was leaving the practice I have built with your ty to care for your patients over the past five
been under the care of Dr. Sawyer. He will also see help over the past five and a half years in and a half years. It has truly been my pleasure
patients on other weekdays out of his office. Chicago. I have developed deep and lasting and privilege to do so.
relationships with many of you, which I will
In addition, we will refer children with spinal truly miss. I would like to thank you for trusting If you have questions or concerns, please
deformity problems to our nationally renowned me with the care of your patients, a respons- feel free to contact me at any time. After
spine surgeon — Howard An, MD, who also spe- ibility I was honored to have. I have strived July 21, I can be reached at the Campbell Clinic
cializes in adolescent cases. Or, in the case of a to give each one of your patients the highest in Memphis at (901) 759-3254 or online at
sports medicine problem, we will refer the patient quality care possible. www.campbellclinic.com.
to Nikhil Verma, MD, a sports medicine subspecial-
After three to four weeks on an orthopaedic Respectfully,
ist. Both Dr. An and Dr. Verma worked extensively
with Dr. Sawyer. mission trip overseas, I will start practice again
Jeffrey R. Sawyer, MD
For the longer term, we continue to assess our
ability to provide pediatric orthopaedic services,
26 Orthopaedic Excellence
Surgeon Treats Haitian Patient with Clubfoot
By Lisa Files
ost children take their first steps by age 1 or for such a surgery would have normally ap- couldn’t communicate with her first host family.
2. Marie, a little girl from Haiti, took her first proached $50,000, according to Dr. Sawyer. She also missed her parents and three brothers
steps recently at age 9. Born with clubfeet in Clubfoot is the most common birth defect, and three sisters.
the poorest country in the Western Hemisphere, occurring in one in every 200 to 300 babies.
Marie hobbled or crawled and did not attend Researchers don’t know the cause, and some Then Childspring International found Franco and
school, fearing scorn from classmates. But pro think there is a genetic component. Carole Valdemar and their 5-year-old daughter,
bono surgery at Rush Oak Park Hospital in Caroline. The family is from Haiti, speaks Creole,
February 2005 changed all that. “It might be related to how the baby is positioned and agreed to host Marie in their Waukegan
inside the mom,” suggests Dr. Sawyer. “If you home. “Poor Marie was crying every day before
“Marie is taking some steps. She walks with a have a big baby and a small mom, the feet are she came here. She wanted to go back to Haiti.
walker now,” boasts Franco Valdemar, her host kind of tucked underneath. We don’t fully know. But now she is happy. She has no problem at all,”
family father in Waukegan. Marie’s clubfeet were way worse than what we says Franco, a minister with the Evangelical Free
Jeffrey Sawyer, MD, a pediatric orthopaedic spe- see in the United States and pretty bad compared Church of America.
cialist with Midwest Orthopaedics at Rush, made to what we see in the rest of the world because in
the initial contact with Marie. the United States, we treat kids before they’re Dr. Sawyer confirms this. “That family has been
walking on their feet, by 9 to 12 months.” instrumental. She wouldn’t have done nearly as
“Childspring International sent us a photograph
well without them. Surgery is surgery, but that is
of her,” he says. “They couldn’t send us an x-ray.
such a small part of her total care. It is really the
Her family lives in a farming village where there
after care that is the majority of the work.”
isn’t even a telephone, let alone the Internet.”
Childspring International matches children from Finding the right host family for Marie fulfilled
poorer countries who need expensive medical Childspring’s mission to heal the whole child —
treatments with physicians and hospitals in the physically, mentally, emotionally, and spiritually.
According to Helen Shepard, Director of
Of course, each physician is not an island. Dr. Development for Childspring International,
Sawyer had to enlist the help of a surgical team as “Sometimes people like Marie are shunned by
well as Rush Oak Park Hospital itself. “We had their community and don’t attend school. By cor-
more than enough people who wanted to volun- recting her physical deformity, this will open many
teer their time and talent,” says Dr. Sawyer. “Dr. doors. So Childspring will follow up with an edu-
Simon Lee, a foot and ankle specialist, helped with cational scholarship for her back in Haiti.”
the surgery. Dr. Ahmed Elborno was the anesthe-
siologist. Sue Gilpin was our physician’s assistant, For her part, Marie looks forward to walking, run-
plus all the nurses. There were probably 10 to 12 ning, and playing with family and friends in Haiti.
people total. It was a tremendous team effort.” She even has an idea for a new business from her
Capable Hands stay in Illinois — packaging and selling snow.
Rush Oak Park Hospital was chosen as the venue Childspring International seeks the following help:
Clubfoot is a congenital foot condition, which is caused by
for the surgery for its small size and efficiency. It the position of the foot in the womb. hosting a child; supporting a host family; sharing
was performed on a Saturday, when the caseload contacts in the medical, corporate, and civic com-
Dr. Sawyer has performed between 100 and 200
is lighter. Bruce Elegant, Chief Executive Officer at munities; donations; and simply spreading the
Rush Oak Park Hospital, estimates 30 people were clubfoot surgeries in places as far away as Malawi,
Africa, and Abu Dhabi, United Arab Emirates, word to others.
involved in Marie’s care, including dietitians, social
workers, and others involved in the follow-up where he has been a visiting professor of
Write to Childspring International, 1328 Peachtree
after surgery. orthopaedic surgery.
Street NE, Atlanta, GA 30309-3902, visit
“It was an effort on behalf of everyone to support Healing the Whole Child www.childspringintl.org, or call (404) 228-7744.
the mission of the hospital, which is to serve While physically Marie has had the best care, she
the community, in keeping with the traditions had a rocky beginning after her arrival in the Article reprinted with permission provided from
of Catholic health care,” he says. The dollar total United States. Speaking only Haitian Creole, she Wednesday Journal, Inc.
Orthopaedic Excellence 27
Preventing Malpractice Suits
While Educating Patients
Does It Get Any Better Than That?
By Dennis Viellieu
ne of the hottest topics in health care today is the actual defense, which can run in excess of
medical malpractice. Virtually every physician $500,000, according to the Physicians Insurance
in the nation has been affected in one way or Institute of America (PIIA). Unfortunately, projec-
another by medical malpractice, and we in Illinois tions show little sign that the cost of malpractice
have been more impacted than most because of suits will decrease in the near future.
our regulatory environment.
The Role of Communication
In addition, specialty practices like ours in Many medical practices have taken steps to battle
orthopaedics, as well as neurosurgery, obstetrics, this trend, including establishing detailed quality-
and gynecology, are subject to the highest number assurance process improvements, reducing the
of claims. As a result, we pay some of the highest number of risky surgeries they accept, and employ-
premiums. Thankfully, Illinois finally passed legisla- ing other complex, risk-reduction strategies. These
tion that will provide some relief in this arena, but are all excellent tactics, but they do not take into
make no mistake, the actual relief is still a long way account one critical element in the malpractice liti-
off and doesn’t completely correct the problem. gation equation — patient expectations.
A 2002 annual report, “Current Award Trends in An April 2003 article in the Archives of Surgery
Personal Injury,” published by Jury Verdict Research notes that after more than two decades of study-
reports that the median jury award in medical mal- ing factors influencing malpractice, “it is clear to
practice cases is now more than $1.1 million. These us that lawsuits are not about bad outcomes...they
figures exclude the time spent by physicians, staff, are about expectations.” That is, most malpractice
and administrators preparing and participating in claims are the result of complications that are
normal and expected for the procedure per-
formed, but the patient feels he or she was not
There are nine procedures properly informed or made aware of them.
currently offered by EMMI: Despite the limitations and unpredictable na-
EMMI combines clinical and legal best practices in a Web-
• Total Knee Replacement ture of medical outcomes, patients steadfastly based, interactive, patient-education series that manages
hold physicians to a higher, almost idealized the expectations of people who are scheduled for surgery.
• Total Hip Replacement standard. Because of this, patients with mis-
• Anterior Cervical Disc Fusion (ACDF) managed expectations are more likely to litigate A recent article in The New York Times noted that
than those patients whose expectations are “only 15% of patients fully understand what their
• ACL Reconstruction
properly managed. physicians tell them and 50% of patients leave
• Knee Arthroscopy their physicians’ offices uncertain of what they are
While most physicians are committed to the supposed to do to take care of themselves.”
• Carpal Tunnel Surgery concept and work diligently to communicate Effective communication is particularly challenging
• Shoulder Arthroscopy effectively with their patients, time constraints, for surgeons and other specialists who are often
individual communication styles, and the ability of performing one-time procedures on patients with
• Lumbar Laminectomy the patient to understand medical terms and whom they have little or no relationship.
• Lumbar Microdiscectomy procedures can severely compromise a patient’s
understanding of preoperative and postoperative Informed Consent
• Posterior or Transforaminal Lumbar
procedures and outcomes. Additionally, language Although there are procedures in place that
Interbody Fusion (PLIF/TLIF)
barriers and cultural differences can often further are designed to address patient expectations
complicate physician-patient communications. and protect the physician, the most common
28 Orthopaedic Excellence
procedure, the traditional informed consent program for the procedure via computer, either in of the procedure can be printed for later refer-
agreement, does nothing to ensure that a patient the office or from home. Our patients have been ence. A series of questions ensures the patient
actually understands what they are consenting to. extremely enthusiastic about this new program is engaged in the program and allows him or her
Limitations of the informed consent process are because it allows them to go through the materi- the opportunity to delve further into any topic
numerous and pervasive. They are written in rela- al at their own paces with family or friends, who for clarification.
tively complex medical terminology, making it dif- often need to understand the procedures as
ficult for the average adult to understand the Additionally, patients may repeat information
well to properly assist with preoperative and
information presented. they would like to review again or skip sections
postoperative care instructions. Through a series
they have already reviewed. Some programs also
of interactive modules, EMMI reviews and details
Elderly patients find them particularly difficult allow the patient to post questions that the
the entire preoperative and postoperative experi-
because they are significantly limited in their abili- physician can answer by phone, by e-mail, or at the
ence, providing information about risks, benefits,
ties to recall complex information relative to next office visit.
younger patients. Traditional procedures for and alternatives.
obtaining informed consent also do not adequate- Keeping Patients Safe
The series of interactive modules begins with a
ly promote patient comprehension of the informa- This approach to patient education can help
brief anatomy lesson and then walks the patient
tion provided. One patient survey indicated that reduce the frequency and severity of malpractice
through the entire preoperative and postoperative
69% of patients admitted they did not read the cases in a number of ways. First, by providing a
process in an engaging, easy-to-understand
consent form at all. Finally, consent forms are not tool to educate patients on the basics of the pro-
manner. The material is written at a sixth-grade
nationally uniform. cedures they will undergo, physicians can use
reading level and at a fourth-grade health-literacy
office visits to answer specific questions and con-
A study of 157 hospitals nationwide discovered level, as recommended by health care educators,
cerns, allowing them to not only provide vital
that only 26.4% of the consent forms included to maximize comprehension and retention. For
information but also improve their relationships
the risks, benefits, alternatives, and other impor- example, a patient undergoing an orthopaedic
with the patients.
tant aspects of the procedure. It is not surprising procedure such as a total knee replacement,
therefore that, as noted in The Intelligent Patient’s would see a detailed illustration of the anatomy of Second, improving patient understanding of the
Guide to the Doctor-Patient Relationship, 40% to the knee and the results of its deteriorating condi- procedure helps to ensure they better follow
60% of all malpractice suits today allege improp- tion. The risks and benefits of the procedure are physician instructions, which leads to fewer read-
er informed consent. Despite our best intentions, also presented, along with the steps the surgeon missions, shorter recovery times, and, ultimately,
we are missing the mark. will take to repair the knee and what the patient patients who are much more satisfied with their
can expect to experience after surgery. overall surgical experiences.
The good news is that patients who understand the
full scopes of their procedures are much less likely As the program progresses, patients are offered EMMI enhances traditional informed consent
to litigate. Furthermore, these patients also have the opportunity to take notes, and a summary by capturing and documenting the entire >>
better outcomes, thereby managing overall costs
for hospitals, health plans, and insurers. Managing
patient expectations, therefore, is not just good EMMI and the Patient Experience Each EMMI has seven sections:
medicine — it is the key to helping patients obtain
the optimal benefits from medical or surgical proce- EMMI improves the overall patient
Your Body: basic anatomy
dures, reducing the risk of malpractice lawsuits, and experience by explaining in an easy-to-
lowering the cost of health care. understand manner what a patient can
expect before, during, and after an Your Condition: why you need
Patient Communication Tools surgery
upcoming medical procedure.
In our practice, we have used a patient education
and informed consent program called Expectation As the patient interacts with the pro-
Before Your Surgery: pre-
Management and Medical Information (EMMITM) gram, each click is recorded to create a
since the beginning of the year for 10 different permanent record of everything the
orthopaedic surgeries. EMMI combines clinical patient saw, heard, and did while view- The Procedure: step-by-step
and legal best practices in a Web-based, inter- ing the program. explanation
active, patient-education series that manages
If necessary, the entire patient experi-
the expectations of people who are scheduled
for surgery. ence can be recreated for judge or jury After Your Surgery: recovery
in the event of a malpractice claim.
EMMI serves two purposes: First, it educates
patients on the procedures they are scheduled to Risks and Benefits: commonly
receive, and second, it enhances traditional known
informed consent by documenting the process of
informing the patient of the inherent surgery risks. Alternatives: other choices,
Once a procedure is scheduled, the patient is if available
given a code that allows him or her to access the
Orthopaedic Excellence 29
information exchange, making it a powerful risk- ensuring we can continue to provide optimal care There are currently EMMI programs available for a
management tool. As the patient interacts with for all patients. wide range of surgical and medical procedures,
the program, each mouse click is recorded, creat- including orthopaedic, cardiovascular, obstetrics/
ing a permanent record of what the patient saw, gynecology, general surgery, bariatric, plastic/cos-
heard, and did while viewing the program. metic surgery, as well as many others. All EMMI
EMMI is a powerful risk-management and patient- programs are developed by board-certified sur-
This type of quantifiable evidence of the patient satisfaction tool developed by Chicago-based geons in their respective fields.
experience helps reduce malpractice risk for hospi- Rightfield Solutions, LLC. Introduced in 2003, EMMI
tals and surgeons by providing irrefutable evi- has been provided to more than 45,000 patients, For additional information on EMMI, visit
dence that a patient was presented with the 500 surgeons, and a growing number of hospitals, www.rightfield.net or contact Jordan Dolin at (312)
appropriate information, particularly the risks and medical groups, leading health care industry 236-3650, ext. 14. For an EMMI demonstration,
benefits, before undergoing a surgical procedure. associations, and malpractice insurance carriers. visit www.emmidemo.com.
The system is easy to administer, and the office
staff is kept updated on which patients have
viewed the program and which have not, so they
can follow up with individual patients. In the
event of a malpractice claim, the entire patient
experience is recreated.
In addition to managing patient expectations and
improving patient satisfaction, EMMI provides a
number of other benefits. Enhanced patient
understanding can lead to a reduced malpractice
risk. Educating patients about their conditions
and the procedures they are about to undergo
improves the quality of communication between
physicians and patients and can result in less
frequent calls to the office staff and fewer
By involving the whole family, the circle of
caregivers important to recovery and supporting
expectations, the EMMI program improves
compliance with physician discharge instructions,
which may lead to fewer secondary complications
and readmissions. EMMI can also serve as a
marketing differentiator that can increase
An Ounce of Prevention
EMMI programs provide a more individualized,
self-paced, and self-directed learning experience,
but they also hold great promise for empowering
patients to take active roles in their treatments.
Research indicates that an effective mix of audio,
video, and interactivity raises the information
retention rate from approximately 20% to 75%.
Those engaged in the learning process retain 20%
of what they see, 50% of what they see and hear,
and 75% of what they see, hear, and do (i.e.,
what they interact with).
The debate over how to manage malpractice
premiums and reduce claims will likely continue
for years. While the battle goes on, we need
solutions today. An approach that focuses on
managing patient expectations through education
and enhanced informed-consent procedures can
help address the challenges of today while
30 Orthopaedic Excellence
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Orthopaedic Excellence 31
32 Orthopaedic Excellence
Rehab Connections, Inc.
148th & Bell Rd. • Homer Glen
19815-21 S. LaGrange Rd. • Mokena
Physical Therapy by
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Orthopaedic Excellence 33
Midwest Orthopaedics at Rush thanks the following
advertisers for helping make this publication possible.
ACCOUNTING & FINANCIAL SERVICES Physicians’ Benefit Trust .....................see page 11 Working Partners with
Wolf & Company, LLP........................ see page 25 Midwest Orthopaedics at RUSH
INVESTMENT PORTFOLIO MANAGEMENT
ANSWERING SERVICES William Blair & Company, L.L.C. ........ see page 19 PROMOTIONAL PRODUCTS
Communication Centre ......................see page 34 17 Years Experience
ATTORNEYS Omnia Marketing & Design ...............see page 23
77 West Wacker Dr., Ste. 4100 C Gifts
Chicago, IL 60601 FugiFilm..............................................see page 32
(312) 849-8100 • (312) 849-3690 Fax
Physician Sales & Service, Inc. ............see page 33 C Sales Promotions
OFFICE EQUIPMENT C Ad Specialties
Chicago Office Technology Group
Citibank..........................................see back cover Call for a free catalog
1 E. Wacker, Ste.1305
Chicago, IL 60601
BIOTECHNOLOGY PRODUCTS & SERVICES
(312) 923-7200 708-396-0420
55 Cambridge Pkwy.
Cambridge, MA 02142 ORTHOPAEDIC SUPPLIES
(800) 284-2876 Visit us on the web
DonJoy . .............................................see page 31
PAIN MANAGEMENT SERVICES
Apac Groupe .......................................see page 5
Illinois Collection Service, Inc. .............see page 25
PHYSICAL THERAPY & SPORTS REHAB
Accelerated Rehabilitation Centers ....see page 11
American Data and Voice ...................see page 31
AthletiCo ...........................................see page 32
Applied Communications Group ........see page 15
NovaCare Rehabilitation .....................see page 19
HEALTH CARE BUSINESS SOLUTIONS
OccuSport Physical Therapy ...............see page 23
Itentive ...............................................see page 25
Performance Physical Therapy ............see page 31
HEALTH CARE SOFTWARE
Physiotherapy Associates ...................see page 25
Merge eFilm .......................................see page 10
Rehab Connections, Inc. ....................see page 33
HEALTH CARE TECHNOLOGY
Scribe .................................................see page 25 WCS Physical Work Re-Training .........see page 15
HEALTH INSURANCE BROKERS & CONSULTANTS PROMOTIONAL PRODUCTS
Benefitdecisions, Inc. Presto Marketing, Inc. ........................see page 34
125 S. Wacker Dr., Ste. 2075
Chicago, IL 60606 PROSTHETICS & ORTHOTICS
(312) 606-4800 x303 • (312) 606-8101 Fax Scheck & Siress. .................................see page 30
HOME HEALTH & HEALTHCARE SERVICES RADIOLOGIST SERVICES
Girling Healthcare, Inc. ......................see page 32 Affiliated Radiologists, SC .....see inside back cover
ReliaCare Home Healthcare ...............see page 23 X-RAY PRODUCTS
James X-Ray Co., Inc.
HOSPITALS & HEALTHCARE SERVICES
505 Harvester Ct., Ste. F
Rush SurgiCenter ...............................see page 33 Wheeling, IL 60090
(847) 279-0513 • (847) 279-0516 Fax
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34 Orthopaedic Excellence
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