The Beauty of Motion

Almost every day of our orthopedic careers, there is something new to be learned. We regularly look to someone who is adept at offering advice on difficult clinical decision making and who is able to navigate through challenging surgical cases and provide advice on practice management. These mentors are truly the unsung heroes of our profession, their importance paramount to the continued success of orthopedics. At a time when the challenges facing our profession are daunting, we are fortunate to be able to rely on our mentors, who have navigated the waters and serve as beacons of sage wisdom. The continued success of our profession is dependent on sustained and efficacious mentor relationships.

We have all known individuals who were critical to the successful completion of our training. Perhaps it was the senior resident who took the time to demonstrate wrinkle-free plaster application after a distal radius reduction, or the senior surgeon who assisted with a complex rotator cuff repair case. The common thread in mentorship is that someone with knowledge and experience on the subject took the time to educate a fellow surgeon or surgeon-in-training. Often the true value of time spent in the mentorship process is never recouped; however, rest assured that the lifelong attainment of knowledge is priceless. These days when our time is so taxed, the mentorship process is still an invaluable part of our work for both the mentor and the individuals who benefit from his or her experience, knowledge, and wisdom.

I first learned the value of mentorship while in college. An orthopedic surgeon there introduced me to the world of medicine and injury prevention. Thanks to his guidance, now as colleagues we often discuss our respective clinical practices and the challenges we face as orthopedic surgeons. As a medical student, I was fortunate to learn from physicians who took the extra time to ensure that I learned what it meant to be an orthopedic surgeon as well as a researcher. My first research publications were possible due to their tireless efforts to show me how to conduct a sound research study and write a coherent manuscript. I credit my sustained interest in academics largely to these individuals who took the time to cultivate and nurture a young, impressionable orthopedic student.

My orthopedic teachers are true mentors and have served as sounding boards as I continue my orthopedic training and develop my own practice. From my first case as staff to complex clinical decision-making scenarios, mentors have played a profound role in my professional development as an orthopedic surgeon. My mentors are too numerous to count. Suffice it to say that we all owe a debt of gratitude to those who have helped shape our professional growth. As I transition from mentee to mentor, I am reminded of the importance of mentorship for sustained orthopedic success.

One does not have to be in an academic practice to have mentors. Junior and senior partners and other professional colleagues can serve as mentors to nurture the development of others. Our colleagues and peers are also mentors, each of them offering their varied strengths to counterbalance inherent weaknesses. I am confident that we all know someone we can e-mail tonight with the most difficult of revision cases to ensure we are doing the best for the patient.

I am unable to mention everyone who has served as one of my mentors. However, in today’s orthopedic world of complex reimbursements, health care spending and allocation, dwindling time for resident and fellow education, and more work demanded of all of us, the mentorship role becomes increasingly important to the continued viability of our specialty. The people in our field are our most important assets, and although I did not truly realize it early in my training, I owe a huge debt of gratitude to my mentors. In some small way I am now attempting to repay some of that debt by mentoring other students, surgeons, and clinic staff. I find this new role both professionally gratifying and intrinsically rewarding. The benefits of mentorship outweigh the additional time or money spent educating others in orthopedics.

My challenge and appeal to you as fellow surgeons is to think of ways you can mentor someone. They may not realize it or thank you right away, but your selfless dedication to the profession as a mentor will allow someone to reap lifelong benefits.

Tags: education, Life, medical, medical student, Mentorship, Orthoapedic Residency, Orthopaedics, Pearls of Wisdom

“A man’s errors are his portals of discovery.”

…James Joyce

Orthopaedics residency, for me, was a wonderful experience. The camaraderie between residents and surgical services was wonderful. It almost felt like being in a fraternity. You scratch my back and I’ll scratch yours. We looked out for each other. I always felt I could count on my fellow residents to cover my back. On the same note, we always had attending supervision. Therefore, when things became a little more difficult, there was always someone senior to step in and complete the task. During this time, I never felt sick. I never felt a sense of doom.

As an attending, especially in the first couple of years in practice, there are times when you just want someone to take over the case. You may be in a trauma or revision total joint and have planned everything out. You have all of the equipment, etc.. You feel you are well prepared. You even looked in the “books with pictures” and reeducated yourself on the complexities of the procedure at hand. You have looked at all of the bold faced and italic items. You may have even checked with your senior partner to make sure you have not missed anything. Now you are ready.

After the case has begun, you go step by step. Things are going well. Then, something changes. An alteration from what you saw in residency or a change from what you read in the book. Maybe there is a bleeder you can’t get or a critical screw that has broken out or you lose motor and/or sensory evoked potentials. This is what separates the men from the boys. At first, you will have a sinking or nauseous feeling. This is the time you need to become very focused and concentrate on what needs to be done. This is not a drill. You have to start thinking clear and concise. You have no one to bail you out. As in a code situation, first stabilize the situation (i.e. for a bleeder, put your finger on it or pack it), then calm yourself down (your adrenals will have been squeezed, and you will be shaky), gather your thoughts, and begin to go stepwise through and fix the procedure. The most important thing to understand, if you have a partner in the OR or close by in the office, REQUEST HELP. This is not the time to be bull headed and feel you can do everything. It is not a sign of weakness. It is smart to get someone who is not involved to look at the situation objectively.

Once the situation is stabilized, and the patient is out of the room, I feel it is important to look critically at the case and understand the errors you may have made in initial assessment, surgical approach and exposure, surgical technique, and emergency management. In the military, this is known as an After Action Review (AAR). I feel this is an important step in the growth of a surgeon / physician. The ultimate AAR is M&M (morbidity and mortality) or D&C (deaths and complications). In M&M, we can learn from others mistakes or misfortunes and hopefully apply that experience to our own practice.

This situation does not only apply to the OR. It can also happen in clinic. You may be in clinic and have a patient that comes with the same complaint and you realize they have a different problem than you initially thought, or maybe a fracture reduction has lost it’s position, or a wound looks infected, or your surgery has fallen apart. You will get the same sense of impending doom. It is important that you act on these appropriately. You may ask a partner what he or she thinks. This is an objective view and takes away our biased view of the situation. It is always easier to see someone else’s error. DO NOT neglect the situation. If you think there is a problem, prove it is not. When I was a junior resident, one of my chiefs said to me, “If you think it is infected, it is infected until proven otherwise.” These words stuck with me.

In the end, remember we are all human. It is important to know your limitations. These limitations become more evident with experience. When you get to the extents of your knowledge base, experience level, or comfort level, ask for help. We go in this specialty to help not harm patients. It is not time to have an ego. If you do what is right and are honest with yourself, you will gain the respect of both you peers and patients.

Tags: Learning, Orthoapedic Residency, Pearls of Wisdom, Teaching

When I was in medical school, one of the key issues that discussed at the time was the increasing need for primary care providers and the over abundance of sub-specialists. There was a push by multiple institutions to increase medical students interest in the primary care areas and a deemphasis of the sub-specialties. Over recent years that prediction was found to be off target. Unfortunately, the opposite was found to be true. One of the causes for the miscalculation was an aging population and a predicted increasing need for care including sub-specialty care. Along with the general population, the orthopaedic workforce is also aging. There are a number of the elders who will be retiring in the near future with no one to fill their position or role.

As we go through our medical education and resident training, there are a few individuals who have a lasting impact on those with whom they have interacted. These are the individuals that many years later are still quoted and mimicked. In many instances, these individuals have dedicated their lives to the education of the young physician and the advancement of medical knowledge. Not all of the memories may be good memories, but they have effected you none the less. If you close your eyes and visualize your education, these are the people you see. The more time a person is associated with a program; the more they become a part of that program. They are fixtures at that program, an “institution”.

As is the nature of life and careers, they all have to come to an end. Recently, I heard that one of my mentors has cut back his practice. He has not retired, but he has decrease his case volume and stopped performing major procedures. This past week I was reminiscing with some former residents from my program. As you do, we talked about our current practices, how many kids, new relationships, new cities, etc. After we finished with the formal updating of our lives, we reminisced about residency. We laughed about the good and bad. We all had a lot to say about my former mentor. It was very interesting that everyone had very similar stories. While I was still in residency, I remembered having other former residents tell these same stories to me. As we talked about him, I found out that he had cut down his practice. We all had a feeling of sadness about it. It seemed like the end of an era.

When a program loses someone who was influential, part of that program dies. As with many tribes, they depend on the elders to impart wisdom and insight. It is with this wisdom we are able to stay away from mistakes of the past. They remind us of previous successes and failures. Because of their years of experience, they are able to quickly reference the patient catalog and give advise base on previous experience. In their mind, it intuitively “makes sense.” It is true their techniques make have fallen behind the current en vogue treatments and/or techniques, but it is their experience that is vital to the education of both medical students, residents, and young attending staff.

In my specialty where 60% of the Orthopaedic Society of North America members are over the age of 50, the era is coming to an end in multiple institutions. Unfortunately with the current generation of attendings and residents (GEN X) choosing sexier and more lucrative specialties such as sport medicine and spine surgery, the number of specialists in the other specialties has decreased. For a number of reasons (malpractice, case volume, lower salaries, interest), residents have shied away from some of the other specialties. We know the mentors and sub-specialty exposure influences resident selection of sub-specialty. With many of the great educators reaching retirement age, who will assume the role?

I look back at my own education and remember how much I was influenced by my faculty. Both in my fellowship and residency, it was the wisdom of my elders which particularly influenced me. As I look to the future, I hope these voids will be filled. This is an unknown. In the end, all I can do is hope and pray that this is only a cycle and we are on the bottom end of that cycle. If not, may be at the beginning of an ice age.

Tags: education, hospital, medical, medical student

Hollywood, sometimes casts a beauty as a not very believable, white-coated scientist. But there is a real one who got into trouble for removing, on film, more than her white coat.

Hedwig Eva Maria Kiesler perhaps better known as Hedy Lamarr (1913-2000) was a stunningly beautiful woman who contributed, in 1942, the science behind a communications invention still referenced today in connection with WiFi development.

Hedy Lamarr was born in Vienna. After ballet, piano, and acting studies, she made her first film as a teenager. Her first hit movie “Ecstasy” in 1933 had many nude scenes where her orgiastic shots were achieved by the director sticking the point of a safety pin into her rear. She married an Austrian arms manufacturer and learned much about military hardware from him and his company, at board meetings. Moving to the United States in 1937, she was hired by Louis B. Mayer and started a successful career as a Hollywood actress, making 29 films. She became involved in the second World War effort and for it in one evening, she raised $7M.

With George Antheil, an American music composer (mostly jazz), who was a neighbor at her Hollywood home, she tried to further the American war effort by inventing a device to control the direction of torpedoes. It was called “Secret Communication System” and received US patent No. 2,292,387 on August 11, 1942. Although supported by other scientists, it was ignored by the Navy brass. What she and Antheil invented was a system of “frequency hopping” based on player piano paper rolls used to cause changes among 88 radio frequencies (88 keys on a piano). It made radio-guided torpedoes harder for enemies to detect or jam. Two decades later developments in electronics made the invention easier to manufacture and it was first used for communications among United States ships at the Cuban blockade in 1962. It is the basis for “spread spectrum” communication technology used in WiFi network connections.

Hedy Lamarr’s science was before its time but its worth was recognized and honored by an award from the Electronic Frontier Foundation in 1997.

Hedy Lamarr died in 2000 at her home near Orlando. Her son, Anthony Loder, scattered her ashes, as she had asked, in the Vienna Woods.

Tags: Hedy Lamarr, WiFi

I was told once by one of my mentors that “not everyone will like you.” At the time I didn’t understand the wisdom in that statement and just went about my day. As I progressed through residency, fellowship, and into practice, I have begun to understand the enormity of that statement.

I’ll take you back to summer 2008, for the orthopaedist, this is the busy season. Both elective and emergent surgical cases peak, and clinic volume is maxed. So, let it be known that my wife hates this time of year. I was consulted by one of my general surgeons colleagues about a difficult case. He asked if I would review the chart and radiographic studies and help them come up with a plan of action. I told him I would review everything and get back to him.

After my cases were completed, I sent the residents on their way (they had to prepare for conference in the morning). I started rounding on my patients. It was more like social rounds. You know, “how are you doing? … and yada yada yada.” This is usually quick; it’s not work rounds. Patients like to see their “doctor” even if you aren’t really doing anything. I started with my inpatients. I went into each room and sat on the edge of the bed and talked to the patient and his/her family. I answered a number of questions; then I was off to the next room. I had had no difficult patient issues.

The last room I visited was the room of my new consult. I pulled the chart and reviewed the admission note (that I could barely read); I looked at all of the xrays, MRIs, CTs, PET scans, and bones scans. I reviewed the previous operative notes and pathology reports. Needless to say, this patient had been through a lot in his short life. The next step was examination of the patient.

I walked in to the room. There was mom, dad, sister, cousin, and friend. I introduced myself to them all and discussed the reason why I was asked to see him. I talked with mom (who is in the medical field) and dad for a bit to get a sense of what had been done previous and what recently gotten him to this hospital stay. Then I sat down and talked to the patient. I began by talking to him about school, girls, his new PSP. We talked about some of the things he liked about school and what his aspirations where in life. I then began to talk to him about his symptoms and how things had changed. I did a quick exam of the areas of concern. Then we discussed what I would propose to do. I think I spent may be 20 minutes in the room. Everyone was on board with the plan. I contacted my colleague and scheduled the surgery for the next day.

The next day we preformed the procedure. Afterwards, I went to talk to the family. and informed them of the outcome and the future plans. At the end, the mother says to me how appreciative her son was of how I treated him. She informed me that I had been the first person to sit down and speak to him in a language he could understand. She actually began tearing up. I said thank you. I checked on my patient in recovery room. When saw me, he began to cry and began thanking me for taking care of him.

As much as we complain about number of hours in the hospital, poor reimbursements, bad hospital administration, insurance dictating care, and increase in malpractice cases, one of the things that is sometimes lost is the care of the patient. We are taught both in medical school and residency to take care of diseases that patients have and not how to take care of people. Sometimes we get so caught up in our own issues and forget that the patient is not a disease s/he is a human being.

Not everyone will like you. This is something that you will encounter throughout your training and careers. Your purpose should not be to have the patient like you but be to provide good overall care of the patient (person) and family. In this particular instance, I did not do anything different than I normally do, nor do I think what I did was extraordinary. I try my best to treat the patient as much as I do the disease. That day I succeeded in remaining human. We will see how I do in the coming days.

Tags: Patient, Patient Management

A recently published book caused me to examine what some of my colleagues have done in their orthopedic practices in terms of adopting a team approach to health care in an effort to offer higher quality and efficiency. In Redefining Health Care, Michael E. Porter and Elizabeth Olmsted Teisberg propose that the nation’s health care system is using “21st-century technology delivered with a 19th-century system” and that our sector of the economy is one of the last to have significant reconfiguring.

Porter and Teisberg emphasize that hospitals should closely follow cases, track survival rates, recovery times, and patient satisfaction, etc. They note that someone needs to consider the different visits, different buildings, different times and ensure the doctors and studies are available within a reasonable and efficient time period for the patient.

One stumbling block in this transformation will be, “Physicians no longer should see themselves as isolated,” Porter writes. “They need to see themselves as part of a team.” To me, this means the solo fighter-pilot mentality of many orthopedic surgeons (including yours truly) will have to change to flying more in formation. That will mean more oversight with standardization, documentation and regimentation in our practices. This change is proposed to benefit patients and increase efficiencies for all.

Personal experience

This year I came to appreciate the potential for the team approach to medical care when members of my family were evaluated and treated at two different centers using this method. They had a head physician of international stature and a center approach to the diagnosis as well as numerous supporting physicians, physician assistants and other dedicated professional staff. The laboratory studies and data collections were not that intrusive on our time. We could do much of the data entry in advance on the Internet, during the visit and/or with a research assistant. The centers provided their specific outcomes on proposed treatments as well as their failure and complications rates, which we found helpful in the decision-making process.

Our visits and treatments were coordinated so they could usually be completed in 1 day or less when possible and our appointment was dedicated to individual care. While I was pleased with the medical care, it involved travel, staying in an adjacent hotel the night before, and in some cases arguing with the insurers as the treatment was considered not being the standard of the community — lacking peer-reviewed, published articles with 2 year follow-up.

The treatment was more expensive then what is available locally, but it was worth the slightly higher costs to my family. The alternative would have required more of our time and frustration trying to get all the results and recommendations in one place at one time. I realize all community hospitals cannot have the volume, physician specialization, donations and grants to support the impressive team approaches, research documentation and follow-up we experienced. However, all can start applying some of the techniques to those specific areas where they do have the most volume.

Time-saving approach

As orthopedic surgeons in the outpatient environment, we can more easily achieve (and most of you have) the benefits of the team approach to the practice of orthopedics. This involves a streamlined approach from the preoperative setting through treatment and follow-up. Many individual orthopedic outpatient practices have made restructuring adjustments to allow the patient to obtain an expert opinion, have necessary imaging done on site and a treatment decision in one visit.

Compare this approach to having multiple visits to various locations and follow-up visits. For example, having a MRI and/or ultrasound immediately available is something I appreciate. This saves the patient time, by allowing him or her to only miss a half day of work and leave that appointment with a recommendation(s).

Think of yourself and the value of your time. Patients need to be treated the same way. It even has the potential to save in overall costs. One of the current stumbling blocks is obtaining pre-authorizations. This may delay this whole process of minimizing visits for consultations and tests. Most current systems are not concerned about the patient’s hours missed from work and the time they spent traveling back and forth for care, tests, consultations, return visits and waiting for results.

Hospital support

Orthopedic success with the team approach when it involves inpatient care is dependent on mutual cooperation, buy-in and support from hospitals. The hospital becomes a partner and facilitates the approach through its administration and professional staff. Some institutions have utilized well-established team approaches for some time. Emulating aspects of these existing programs can be easily done.

Most of the institutions with successful team approaches have strong physician leadership, a progressive administrative staff, and innovative nurses and therapists in common. Additionally, they often benefit from significant yearly philanthropic donations (nonpatient-generated revenue). In some cases these funds enabled new bricks-and-mortar to establish centers of excellence, supported establishing specialization in areas of new treatment options, and supported innovative programs for nonrevenue-generating professional staff.

Many programs receive grants to help fund their research arms and programs for the needy. The hospital’s demographics and payer mix certainly impacts the availability of this potential additional support to ensure these innovative programs are financially maintainable.

There are examples of team approaches to orthopedic care that do function well and efficiently and strictly within the patient revenue stream. The more organized and efficient they are, the more likely they can reduce overall costs and benefit from volunteerism and the support of patients and family members who have benefited from the higher standard of care.

Orthopedic example

In many institutions, joint replacement is one example of a treatment that has benefited greatly from the team approach. Strong institutions and dedicated physicians have developed this team approach and have viable functional programs currently from which we can all learn.

My personal experience trying to implement many aspects of the team approach to ACL and knee replacement has increased my patients’ quality of care over the past few years. It has included an experienced and trained nurse who coordinates the admission process, collates necessary studies and consultations, plans and coordinates discharge and anticipates after-care needs and conveniences.

We have a dedicated orthopedic nursing service and section of the hospital performing joint replacements. We have excellent therapists and established a new and effective pain control program with the anesthesia department.

In the future, hospitals will be forced to become “team players” with physicians as there will be more pay-for-performance initiatives and “bundling experiments” in which Medicare will make one payment to cover a treatment or procedure and the physicians and hospital will decide how it is distributed. That may or may not be good news, however, the bad news is the proposed bundled reimbursement to be divided with the hospital and the physicians will be less then the current sums paid individually.

Tags: Costs, Organisation, Orthopaedics

I’ve just finished reading an article on the online version of the The Journal of Bone and Joint Surgery. It describes a study conducted by Kaiser Permanente Southern California and shows that proactive measures can reduce hip fracture rates by an average of 37.2% and as much as 50% among those at risk.

It’s the largest study of its kind and over its 5-year period it tracked more than 625,000 male and female patients older than 50 years in Southern California who had specific risk factors for osteoporosis and/or hip fractures. Apparently Kaiser Permanente has a Healthy Bones Program and the implementation of a number of initiatives from this program program reduced the hip fracture rates beyond the goal rate of 25%.

The stats. tell us that about one-half of all women and one-third of all men will sustain a fragility fracture in their lifetime. The mortality rate due to osteoporosis-related fractures is greater than the rates for breast cancer and cervical cancer combined. The principal researcher (Dr. Dell) feels that it’s a misconception that nothing can be done to prevent or treat osteoporosis and is using this study to promote the fact that it’s possible to achieve at least a 25% reduction in the hip fracture rate if a more active role is taken by all orthopedic surgeons.

The National Osteoporosis Foundation reports that although osteoporosis can affect people of all ages, the problem of osteoporosis has reached epidemic proportions with the rapidly aging population. Of the 10 million Americans who have osteoporosis, 80% are women. More than 300,000 hip fractures are reported annually in the United States. Twenty-four percent of patients end up in a nursing home, 50% never reach their functional capacity and 25% of patients with a hip fracture die in the first year after the incident, according to the press release.

Participating physicians in the study implemented a number of initiatives, including increasing the use of bone density test and anti-osteoporosis medications, adding osteoporosis education and home health programs, and standardizing the practice guidelines for osteoporosis management.

I’m always slow to adopt new practices in my clinic on the basis of new research, due primarily do the fact that it’s gotten me into trouble in the past. I’m going to start asking around, however in order to see others experience in the treatment of Osteoporosis as these results are pretty amazing.

Tags: New Research, Osteoporosis

Medicine: what is its purpose, and how has that purpose mutated over the years? Herein lies a major problem confronting the modern healthcare system. Who, what, how, and where are the problems and solutions?

From its inception, the medical profession has been devoted to the diagnosis and treatment of illnesses and injuries affecting humans. The diagnosis of a condition requires first and foremost the taking of an extensive medical history and an in-depth physical examination. Based on information gleaned from this history and physical, a diagnosis should be made and may need clarification through additional diagnostic tools (radiographs, magnetic resonance imaging [MRI], computed tomography [CT] scan, blood work, etc). The additional diagnostic tools should only be used to support the diagnosis by supplying additional information. The coordination of these information-gathering techniques and tools will lead to the cause of the medical condition, thereby providing a more focused treatment plan and usually leading to a more successful result. This has been the objective and pattern of medicine as it existed in the past. Information gathering and an intelligent, educationally based diagnosis equals a favorable outcome (most of the time). This is a great equation.

In today’s medical world, there are many obfuscations clouding the information-gathering process, the diagnosis and, finally, the outcome of the patient’s care. As a matter of fact, the objective of the “medical care” may not even be care of a real injury or illness. In many cases, the “who” recommending or requesting care is not a patient or a physician, it is a lawyer.

Let’s look at a typical scenario. Mr Doe is injured in an accident on the job or in an automobile. If he is not obviously seriously injured, he goes home with little or no medical care. Once home, he contacts his physician, is treated accordingly, and returns to work and normal activities. In the interim, he contacts a lawyer because someone (colleague, wife, friend, etc) has informed him that he should. Soon after, the treating physician is asked by Mr Doe for radiographs, MRIs, blood tests, or CT scans because his lawyer said they are necessary to determine how severely he is “really” injured. The physician is not determining the necessity for additional diagnostic tools, the lawyer, and now the patient, are. The doctor is no longer in control of the medical treatment for this patient. The “who” involved is a non-medical and unlicenced individual whose interest does not lie in the medical recovery of this patient, but in the financial recovery. The “what” is no longer medical, it is now legal. The “how” is in the manipulation of the medical forum and the “where” ultimately is in the courts.

What is the solution? How do we regain control of medical practices? It is not an easy fix. It will take courage and great moral fiber. Take an extensive history and physical. Document your findings and support your diagnosis based on them. If absolutely necessary, support your contentions with only appropriate additional diagnostic tools. Through this thorough and methodical algorithm, you will rule out interference by attorneys. Your records will accurately support or contradict the attorney’s contentions, thereby retaining medical integrity through medical choices.

Tags: Lawsuit, Lawyer, Legal

Joint replacement surgery has evolved over the past four decades into a highly successful surgical procedure. Earlier designs and materials that demonstrated inferior functional and long-term results have disappeared in a Darwinian fashion. Through this evolutionary process many of the current designs have proven efficacy and durability. Technologic advances are necessary to improve implant design; however, in an environment of reduced reimbursement to hospitals, can the cost increase be justified?

Hip and knee implants (in studies everywhere) are yielding excellent long-term results in >90% of patients with 15- to 20-year follow-up. In a recent study by Bozic et al, the cost effectiveness of new technologies was evaluated. Based on their findings, for an alternative bearing with an incremental cost of $2000 to be cost-saving for a 50-year-old patient, there would have to be a 19% reduction in 20-year failure rates. The possibility of cost savings for these alternate bearings in patients aged >63 years is unlikely at current costs.

Newer biomaterials (metal/metal, ceramic/ceramic, highly cross-linked polyethylene) also have limited outcome analysis in patients beyond short- to mid-term follow-up, and all of these technologies add significant cost to the implant. With diminishing reimbursement, careful analysis of use of these newer technologies must be weighed if hospitals are to maintain economic viability.

The high-flex knee designs are another example of implant modification adding cost to the prosthesis. This design is intended to provide greater knee motion for patients; however, many patient-related variables impact on knee motion and there is no well-substantiated evidence that these implants produce knee flexion that is superior to conventional designs.

Computer-assisted navigation for joint replacement adds cost to the procedure both for equipment and added operating time. If these systems, particularly in hip replacement surgery, improve acetabular orientation and leg-length equality, then the cost may be justified; however, this has yet to be demonstrated. Additionally, current systems require multiple pin insertions for tracking devices that may increase morbidity. Navigation system cost must be reduced and the tracking mechanisms must be simplified to justify generalized use.

There is a pressing need to reduce implant costs and generic implants of proven efficacy and quality will be needed in the future. Just as the pharmaceutical and airline industries have evolved to adopt generic/lower cost products, implant companies will have to do the same. With hospital margins falling and at best in the 1%-3% range, price increases for newer technologies will not be tenable. Additionally, implant manufacturers with significantly greater margins will need to lower prices to make these available to patient populations.

Newer technologies must demonstrate their efficacy in long-term follow-up and be superior to conventional implants. If they can achieve this goal, there may be a place for their increased cost in the younger patient with greater life expectancy. As of yet, however, the cost-benefit analysis of these new products indicates clearly that the price increase requested doesn’t justify the benefit (if any) gained.

My forecast is that the orthopaedic sector will go more and more towards the generic style market that has developed in Pharma. The results will be more savings for the hospitals and less (industry financed) trips to congresses in europe, courses in Hawaii and consultancey contracts as the orthopaedic companies start to tighten the belt.

Tags: Market, Orthopaedics

I have strong ties with Italy. My wife is Italian, my mom is Italian and I spent almost all my childhood summers running between the vineyards and beaches of the Adriatic cost (the east coast). I can still remember the scorching hot sun, the blissful relief of throwing myself into the cool Mediterranean, the incredibly healthy and tasty meals my grandmother would prepare and the countless Utopian evenings spent playing with my friends in the golden light of a Mediterranean sunset.

The sun sets over the Adriatic.

As a result of this “Italian Connection” I am lucky enough to have many Italian friends and even a few orthopedic colleagues still present in Italy. In fact, with the help of one of my friends, on every year (for the last 8 years) I go over along with my family for the whole summer, and work in a local hospital. Many say that I should remain at home (in the ‘States) with the kids so that they could spend time with their friends but I prefer to give them the chance to run free in the fields and on the beach, experiencing feelings that a city child will never know.

Yet this is not what I wanted to talk about, rather I’m writing this article to describe the experience and emotions I’ve had as a grown-up Orthopedic Surgeon.

The view from the back garden!!

Firstly, what struck me the most is the trust. I might have Italian roots but I’m not Italian and it’s even more obvious when you look at me (6 foot 2 with freckles) or hear me talk Italian with a midwest accent!. None the less not even one patient has ever questioned my abilities or my qualifications. Back home I know many people who would be afraid to trust any doctor that hadn’t studied medicine in the U.S. and just as we think our schools are the best so too do the Italians yet somehow because you’re part of the hospital and a doctor they automatically entrust themselves to you no questions asked.

There is one elderly lady that always leaps into my head every time I think about going back. She came to me 4 years ago with a severe arthrosis of the hip which was causing her constant and crippling pain and restricting her lifestyle no end. She lives alone and the highlight of her week is Sunday afternoon when she goes to her daughter’s house to eat lunch with her grand-children. The problems with her hip meant that she regularly missed this Sunday appointment and even when she was able to go to her daughter’s playing with the children was out of the question. After a successful hip operation this lady got her life back and now has even gone back to getting around on a bicycle.

Let it be known that I didn’t do anything special, I just did my job without using any special techniques or products. Well, every year I go back, this lady comes to my studio for a check-up accompanied by 3 Stone of fresh fish, gallons of homemade olive oil, 3/4 Salami, freshly baked bread and all sorts of other local food. I perform a check up and we talk about how everything is going, she fills me in on the her grand children’s developments over the last year and shares a good dose of local gossip before thanking me for everything and going on her way.

The fact of the matter is that Signora Cestelli is not unique and I have many more patients just like her. On three different occasions I have been invited for dinner by the family of my patients as a way of thanking me for resolving their problems, and countless others bring me food as a way of showing their gratitude.

Basket of fruit by Caravaggio (I don’t have a photo of the one I received!)

I don’t take advantage of my position and the trust that these people give me. I’m humbled by the way they hand over their very selves into my hands and trust me totally in the conclusions that I reach to make them better. I, on the other hand, repay their trust with an atention and care that I don’t feel many patients get from their doctor.

Back home, I rarely, if ever, find this sort of feeling with my patients. I find relationships much colder and critical. Trust is at a minimun with many patients repeating articles that they’ve read on the internet to contradict what you have to say, almost if they’re afraid that you might take advantage of their position of relative “ignorance” to try out some experimental treatment.

Don’t get me wrong, there’s nothing wrong with my U.S. patients and I totally understand why things are different with respect to, in this case, Italy. That said I can’t wait until next year. I wonder what Sig.ra Cestelli will bring me this time, in her wonderful basket of loaves and fishes.

Tags: Italy, Life