KSF Ortho Volume 2 - Issue 3

Contents
5
5
8
10
14
16
Controlling System-Wide Symptoms
Rheumatoid Arthritis Causes Pain, Fatigue
Moving Forward
Artificial Disc Relieves Back Pain, Maintains Flexibility
Goodbye to Paper
Electronic Medical Records Streamline Record Keeping
One Practice, Many Services
KSF Orthopaedic Center Guides Patients from Diagnosis
to Rehabilitation
Making It Easy
On-Site MRI Simplifies and Speeds Diagnostic Process
14
17
19
20
22
24
26
Strong Bones for Life
Preventing, Treating Osteoporosis Improves Life After 50
Straightening the Curve
Kyphoplasty Restores Spine Height, Shape
The Truth About Total
Knee Replacements
Surgical Procedure Repairs the Knee Rather than
Replaces It
22
Pinpointing the Pain
Shoulder Issues Often Related to Rotator Cuff Degeneration
or Injury
Getting Back to Life
KSF Sports Medicine and Physical Therapy Center Helps
Patients Recover, Thrive
Directory
24
KSF Orthopaedic Center
3
Opening Remarks
O
n behalf of all the physicians and staff at KSF Orthopaedic
Center, I would like to welcome you to the latest issue of
Orthopaedic Excellence, a publication created to explore the many
facets of our practice and provide a forum for issues and interests in the
orthopaedic community.
As the articles in this issue attest, medicine changes rapidly.
Physicians and other medical professionals work continuously to improve
diagnostic and surgical techniques. In doing so, they enhance medical
outcomes, decrease patient discomfort, and improve quality of life. At KSF Orthopaedic
Center, we’ve made staying at the forefront of orthopaedics our primary goal.
This issue features innovative procedures such as artificial disc replacement, exemplifying KSF Orthopaedic Center’s commitment to keep up to date on the latest trends in
orthopaedic health care. This commitment allows us to provide unmatched patient care
and results.
Here at KSF Orthopaedic Center, our physicians and staff comprise a dedicated family. We have 10 orthopaedic surgeons, a neurosurgeon, a physiatrist, and a sports medicine specialist, as well as supportive staff. We work together at two Houston locations
— the main Red Oak location and Willowbrook. We are northwest Houston’s largest
and oldest orthopaedic center.
The health care industry is a significant part of many people’s lives. I’m proud to say
that even though the two KSF Orthopaedic Center locations are technologically
advanced, delivering state-of-the-art diagnostics, surgery, and patient care, they are also
user-friendly facilities. The Internet makes us even friendlier, as it enables patients and
potential patients to schedule appointments at their convenience. Please check us out at
www.ksfortho.com.
We anticipate Orthopaedic Excellence will continually develop and change to meet the
needs of our readers. Great opportunities for progress and enhancement constantly
reveal themselves. We look forward to covering the ongoing advances and innovations
in orthopaedic treatment as well as future improvements in patient care. We hope you
find this issue of Orthopaedic Excellence interesting and helpful.
Sincerely,
Andrew P. Kant, MD
President
A publication from
KSF Orthopaedic Center, P.A.
17270 Red Oak Dr., Ste. 200
Houston, TX 77090
(281) 440-6960
Willowbrook Office
18220 Tomball Pkwy., Ste. 270
Houston, TX 77070
(832) 912-7804
www.ksfortho.com
President
Andrew P. Kant, MD
Administrator
Michael Berkowitz
Marketing Director
Aaron Kant
Orthopaedic Excellence is an educational and
informative resource for physicians, health
care professionals, employer groups, and the
general public. This publication provides a
forum for communicating news and trends
involving
orthopaedic-related
diseases,
injuries, and treatments, as well as other
health-related topics of interest.
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.
Contributing Writers
Diane Calabrese
Mali Schantz-Feld
Orthopaedic Excellence is published by QuestCorp
Media Group, Inc., 885 E. Collins Blvd., Ste. 102,
Richardson, TX 75081. Phone (972) 447-0910
or (888) 860-2442, fax (972) 447-0911,
www.qcmedia.com. QuestCorp specializes in
creating and publishing corporate magazines for businesses.
Inquiries: Victor Horne, [email protected]. Editorial
comments: Brandi Hatley, [email protected]. Please call
or fax for a new subscription, change of address, or single copy.
Single copies: $5.95. This publication may not be reproduced in
part or in whole without the express written permission of
QuestCorp Media Group, Inc. QC Creative is a full-service
graphic design firm, www.qccreative.com. Creative services
inquiries: Todd Hagler, [email protected].
4
Orthopaedic Excellence
Controlling System-Wide Symptoms
Rheumatoid Arthritis Causes Pain, Fatigue
R
heumatoid arthritis (RA) refers to a
chronic disease that causes joint
inflammation and deformity, as well
as an array of symptoms throughout the
body. In addition to joint swelling, tenderness, stiffness, and pain, patients may
experience fatigue, fever, poor appetite, and
general malaise.
RA differs from the more common
osteoarthritis in its system-wide involvement, pattern, and cause. RA often involves
the wrist and finger joints. It typically affects
the same joints on the left and right side of
the body. Patients with RA generally suffer
pain and stiffness for at least half an hour
after they wake up. They often experience
episodes with severe symptoms, called flares,
followed by periods with fewer problems.
Although there is no cure, RA sometimes
will go into remission. More often, however,
the inflammation permanently damages
cartilage and bone tissue over time.
The Cause
RA is an autoimmune disease that develops when the immune system, which
normally protects the body from infection,
attacks joint tissue called synovium that
lines the joints and tendons. The tissue
becomes swollen and covers the joints,
destroying bone and cartilage, producing
inflammation, and damaging the joint.
Unfortunately, physicians do not completely understand the mechanism responsible. Some believe a combination of factors
contributes to the disease.
For example, certain genes may increase
the risk and determine the severity of symptoms. An exposure to something, perhaps a
virus, may trigger the disease’s onset.
Hormones may also play a role, as RA affects
more women than men.
Symptoms
Although RA affects people in many
different ways, including pain in the knees,
hips, and hands, patients diagnosed with this
systemic disease frequently suffer from foot
and ankle problems. During the disease’s
course, more than 90% of patients experience pain, swelling, and morning stiffness in their feet and ankles. These “pedal”
symptoms are the first sign of RA in approximately 17% of patients. >>
KSF Orthopaedic Center
5
Foot symptoms typically start in the toes
and forefeet and progress to the heel and
ankle. Changes in the joints may alter the
patient’s gait. Toes may curl, and bunions,
hammertoes, and corns may develop.
muscles, joint mobility, and flexibility.
Exercise can also improve sleep, reduce pain,
and help with weight management. A physical therapist can tailor an exercise program
to a patient’s abilities and condition.
Lightweight, supportive shoes with deep
toe boxes, arch supports, and orthotic inserts
can help relieve pain and support the feet, as
well as keep them in proper alignment.
Splints worn overnight help prevent contractures. Some patients with more severe
arthritis may find walking with a cane or
some other assistive device helpful.
Diagnosis
Early intervention improves patient outcomes by helping delay or prevent joint
damage. However, RA symptoms sometimes
mimic other diseases, and there is no single
test to check for the disease, often delaying
a correct diagnosis.
To evaluate a patient, a physician will
inquire about symptoms, medical history,
and activity level and will then perform a
physical exam. The physician may also order
x-rays to assess joint deterioration.
Blood tests also prove helpful. The physician will check for rheumatoid factor, an antibody often present in the blood of people
with RA. Other laboratory tests may assess
inflammatory levels or check for anemia.
Conservative Treatment
RA treatment can reduce pain and
inflammation, slow or stop joint deterioration, and improve functioning and health.
Well-informed patients who take active roles
in their care experience less pain and make
fewer physician visits than patients with a
hands-off approach.
Medications, exercise, and self-management skills are therapy mainstays.
Medications may include nonsteroidal antiinflammatory drugs, such as aspirin or
ibuprofen, or corticosteroids to control pain
and inflammation. In addition to pills, the
Feet
Some patients with more severe arthritis may
find walking with a cane or some other assistive
device helpful.
physician may periodically inject steroid
medication into the joint.
Disease-modifying antirheumatic drugs
(DMARDs), including cyclosporine, gold,
and methotrexate, attempt to slow the
disease’s progression. Newer drugs, called
biologic response modifiers, reduce inflammation and prevent joint damage by blocking the immune response. Examples include
etanercept, infliximab, and adalimumab.
Another new agent, anakinra, blocks a
protein frequently elevated in RA patients.
Patients should balance rest with exercise
and activity. Rest helps reduce inflammation,
while exercise is vital to preserving strong
Stages of Rheumatoid Arthritis
Cross-section of small synovial joint showing progression of rheumatoid arthritis
6
Orthopaedic Excellence
Travis Hanson, MD, a KSF board-certified orthopaedic surgeon with a fellowship in
foot and ankle surgery, can correct foot deformities that develop in patients with a severe
form of the disease. It is not a cure, however,
because the disease continues to progress. As
with all surgeries, it comes with associated
risks. Some physicians suggest ankle fusion,
which decreases motion in the foot.
During an ankle fusion procedure, the
surgeon removes the cartilage and, sometimes, adjacent bone. He or she then uses
screws, plates, or rods to bind the bones
together. Ankle replacement surgery may
also relieve pain, but this relatively new
procedure is still under investigation.
Knees and Hips
Albert Cuellar, MD, a board-certified
KSF orthopaedic surgeon with a fellowship
in adult joint reconstruction, is able to diagnose and treat RA of the knees and hips.
While many of his patients have suffered
some sort of traumatic injury like a complex
fracture, his subspecialty is joint reconstruction necessitated by an ongoing
degenerative process like arthritis.
The primary indication for knee replacement surgery is pain of the knee joint. A
painful and dysfunctional knee can severely
affect a patient’s ability to lead a full and
active life. Advancements in knee replacement surgery over the past 25 years have
made this surgery a common and viable
solution for knee pathology.
Arthritis is the number-one reason
people have total knee replacements. Many
patients elect to have the surgery because
the pain associated with arthritis becomes
too unbearable or prevents them from
leading normal and active lives.
RA treatment can reduce
pain and inflammation, slow or stop joint
deterioration, and improve
functioning and health.
Well-informed patients who
take active roles in their
care experience less pain
and make fewer physician
visits than patients with
a hands-off approach.
Hands and Upper Extremities
Alan Rosen, MD, and Korsh Jafarnia,
MD, are board-certified orthopaedic
surgeons at KSF with fellowship training for
the hand and upper extremities. Both
physicians are able to diagnose and treat RA
of the hands and arms.
Generally, the first and most common
complaint is swelling of the hand at the
knuckles that gives the fingers a spindle
shape. This swelling often happens in the
wrist and the large knuckles in the middle of
the hand. The swollen tissue may destroy
the ligaments that hold the joints together
and damage cartilage and bone, which can
result in certain deformities. The wrist may
turn toward the thumb side of the hand,
causing “ulnar drift” of the fingers.
The swollen tissue may also produce
damage that causes the tendons to rupture.
When the tendon ruptures, the patient may
not be able to bend or straighten his or her
fingers. Other possible problems include
swelling that causes pressure on the nerves
(carpal tunnel syndrome) or lumps (rheumatoid nodules) over various joints of the hand
and elbow.
The Future for RA
Scientists continue to study RA and its
causes. They hope to develop new drugs,
targeted therapies, a vaccine, or possibly
gene therapy to treat or prevent the disease.
Some existing drugs used for other conditions also show promise in controlling RA
symptoms. In all cases, however, patients
must work with their physicians to develop
management plans that relieve pain, improve
functioning, and enhance quality of life. OE
For more information about KSF’s physicians and
the treatments available for RA, visit our Web
site at www.ksfortho.com or call our office at
(281) 440-6960.
KSF Orthopaedic Center
7
Moving Forward
BY THOMAS CARTWRIGHT, MD
Artificial Disc Relieves Back Pain, Maintains Flexibility
T
he Federal Drug Administration
(FDA) has approved the CHARITÉTM
artificial disc for use in patients with
disabling back pain. This is an alternative to
spinal fusion, which has been the standard
surgical treatment for low back pain. Over
the last several years, roughly 300 artificial
discs were inserted in patients in the United
States. These patients were part of a research
study, the results of which were submitted to
the FDA in 2005.
Candidates
Don’t get too excited, however. Although the results of the FDA study show
the artificial disc replacement patients did at
least as well as the fusion patients, the
patients chosen for the study met extremely
rigid criteria.
In other words, the artificial disc implant
is not for everyone with back pain. The ideal
candidate will likely have a single-level disc
abnormality, debilitating back pain, and failure to obtain relief after at least six months
of conservative (nonsurgical) treatment.
Other factors such as the age and general
health of the patient are also important.
Discs are soft cushioning structures located between each spinal vertebra. Normal disc function allows for
movement and load carriage.
In the FDA study, patients who had
spinal stenosis (a narrowing of the spinal
canal that causes pinched nerves) were not
allowed to participate, since the disc implant
is inserted through the abdomen and surgery
On the Horizon
More than 5,000 CHARITÉ Artificial Discs have been implanted worldwide since first
appearing in the 1980s. At present, the full longevity of disc replacement devices is not
known. They are expected to endure for 20 to 40 years, depending on the integrity of the
polyethylene insert that fits between the two metal plates.
In some other discs, there is no plastic insert and the metal plates articulate directly on
each other. Although there is only one artificial disc on the market in the United States
now, there are other devices awaiting FDA approval. One of these is PRODISC®, which
has demonstrated good to excellent results in 90% of patients in Europe. Approval of
this device could come from the FDA in 2005. Other artificial discs include MAVERICKTM
and FlexicoreTM.
Artificial disc replacement is an exciting new addition to the armamentarium of
orthopaedic surgeons who offer treatment for back pain. As with other new technologies
and therapies, general acceptance will come as the procedure continues to improve with
better implants to alleviate pain and suffering.
8
Orthopaedic Excellence
to remove pressure from the nerves is done
through the back.
Benefits
The long-term benefit of an artificial
disc replacement compared to spinal
fusion is largely theoretical. By maintaining motion at the operative site, the
artificial disc does not transfer stress to the
other adjacent discs, thereby potentially
avoiding future problems. Only continued long-term follow-up of the FDA
study patients will determine if this benefit
is realized.
The short-term benefits are definite.
Patients with the artificial disc were able to
return to work and other daily activities
more quickly than the fusion patients. In
addition, the fusion patients have restricted
bending, lifting, and twisting ability for
about three months after surgery due to the
fusing bone. Artificial disc replacement
patients only require time for the soft tissue
healing, which allows resumption of activities and exercise much sooner, roughly six
weeks after surgery.
The CHARITÉ Artificial Disc
The endplate component of the artificial disc has small teeth that
secure it to the vertebrae above and below the disc space. The
endplates, each artificial disc has two, are made from medicalgrade cobalt chromium alloy, which has been proven to do no
harm to the body and is used in many other medical implants.
Alternative to Spinal Fusion
It is clear that the artificial disc
replacement will not be a cure-all for back
pain. Patients should continue to aggressively treat back pain nonsurgically with
an emphasis on trunk-stabilizing exercises aimed at the abdominal, oblique, and
extensor muscles.
However, for the ideal candidate
where conservative treatment has failed, the
artificial disc replacement is an interesting
alternative to surgical fusion. If you have
debilitating back pain and want to know
more about your treatment options, please
call (281) 440-6960 for an appointment with
Dr. Cartwright. OE
Thomas Cartwright, MD, earned
his medical degree from the
University of Texas Medical
Branch in Galveston, Texas. He
completed his internship at John
Peter Smith in Fort Worth and his
orthopaedic residency at New
York City Catholic Medical Center.
He then completed two fellowships to further his
expertise on injuries and diseases affecting the
human spine — the first at The Texas Back Institute
in Plano, Texas, and the second at The Center for
Spinal Studies at Queen’s Medical Center in
Nottingham, England. Dr. Cartwright is board certified
by the American Board of Orthopaedic Surgery and is
a Charter Diplomate of the American Board of Spinal
Surgery. In addition, he is a Fellow of the American
Academy of Orthopaedic Surgeons.
KSF Orthopaedic Center
9
T
wenty-first century medical technologies not only speed diagnoses,
but they also minimize the invasiveness and maximize the comfort of treatments. Technological advances also promise
to tackle a great challenge in health care:
the elimination of what sometimes seems
like an endless stream of paper.
It is true that transition from paper to
electronic records involves much more than
plug-and-go technology. Moreover, training
medical professionals and transferring
existing records take time.
However, KSF Orthopaedic Center is
committed to the investment necessary for
full implementation of electronic medical
records (EMRs), says Michael Berkowitz,
Clinic Administrator for the group. Patient
care, internal efficiency, and simplicity in
billing are all enhanced by EMRs, he explains.
10
Orthopaedic Excellence
Indeed, the U.S. Department of Health
and Human Services (HHS) sees the move
to EMRs as a significant way to reduce the
cost of providing the highest quality health
care to all. By removing links in the chain
that accompany paper records — transcription, filing, and storage — information
moves faster and more easily.
HHS and related federal agencies, such
as the Centers for Disease Control and
Prevention (CDC), also point to the
important capacity EMRs have to help
reduce medical errors. The fewer steps in
any process, the more remote the chance of
a mistake.
For example, by ordering prescriptions
electronically instead of using a pad and pen,
a physician can send a request directly to
the pharmacy. At the same time, EMR
systems can compare a drug order against
standard dosages and send alerts to a prescribing physician regarding patient allergies
or drug interactions.
The adoption of EMRs puts KSF at
the leading edge of physician practices
nationwide. In 2005, the National Center
for Health Statistics at CDC reported
that only 17.2% of physician offices used
EMRs, compared to one-third of hospital
emergency departments.
The KSF Experience
“We started the implementation process
in August 2004,” says Berkowitz. By
November 1, 2004, the Sports Medicine
Center at KSF was up and running with
EMRs, serving as a pilot. And by February 2,
2005, the entire clinic at KSF was brought on
board. All new patient records from that day
forward went directly into electronic storage.
“We really started years before the first
phase of implementation,” says Berkowitz.
Everything from selecting a computer platform for EMRs to scheduling the phases of
transition must be done with deliberation,
he explains.
Albert D. Cuellar, MD, an orthopaedic
surgeon at KSF, is the “visionary” who got
the entire effort rolling, says Berkowitz.
“Dr. Cuellar really spearheaded a long and
complicated process,” he explains.
imported to a patient chart directly via
electronic exchange. Eventually, paper faxes
and couriers will be distant memories.
Approximately 140 users rely on
the EMRs at the two KSF locations. They
include 13 physicians, seven PAs, and
seven occupational therapists and physical
therapists, as well as the nursing and
office staff. KSF designated Anisha Malik,
RN, as Project Manager for Electronic
Medical Records.
Showing Results
The adoption of EMRs puts
KSF at the leading edge of
physician practices nationwide. In 2005, the National
Center for Health Statistics
at CDC reported that only
17.2% of physician offices
used EMRs, compared to
one-third of hospital emergency departments.
In the early 1990s, Dr. Cuellar visited a
clinic in Los Angeles where EMRs were
already in use. He came away impressed by
the potential EMRs held for contributing to
the highest quality patient care. At Dr.
Cuellar’s urging, a task force formed to
evaluate the feasibility of transition to
EMRs at KSF. The working group included
physicians, physician assistants (PAs), and
registered nurses, as well as staff from
medical records, the business office, and
the front desk.
The EMR system had to meet criteria of
fidelity and reliability, says Berkowitz. Once
data were stored electronically, there had to
be the certainty that it could be retrieved
without corruption or delay.
After considering several systems, KSF
chose Logician ®, a product of GE Medical
Information Technologies, as its EMR
platform. The system allows physicians and
clinical staff to document patient encounters
and also to share clinical data securely with
other providers and information systems.
It is now possible, for instance, for MRI
(magnetic resonance imaging) results to be
“From the nursing department perspective, we are extremely pleased with the
ability to handle refills and use charts with
no waits,” says Malik. If a patient calls in
regarding a prescription, she explains, a
medical professional can immediately obtain
the records for the patient.
That is true even if another user on the
EMR system is accessing the patient records.
Paper charts, in contrast, often required
“chasing down” because they were in use
elsewhere or had not yet been refiled.
The full implementation of EMRs takes
considerable time, explains Malik. Paper
records must be scanned and converted to
EMRs. Some of that scanning is done in
house, and some is done offsite. In addition,
says Malik, there is the familiarity factor that
must take hold. There is a new lexicon — a
new lingo — that everyone must learn to
describe new processes and also to fine-tune
them, she says.
Consequently, not all choices regarding
EMRs are made at the onset. “There is
continuous decision making,” explains
Malik. “You have to ensure you get information out to all department supervisors in
advance of modifications or changes.”
Berkowitz agrees that the process will be
ongoing. But the happiness of the nursing
staff and business office personnel with
expedited transactions related to pharmacy
and billing has already translated into
making physicians happier, he says.
Physicians can choose to add data to
EMRs directly throughout the day as they
see patients. They can enter data directly via
a keyboard or by voice. Results of laboratory tests and imaging and surgery reports
are already imported to the system by
electronic transfer. The need for fewer
transcription and clerical services means a
reduction in operating costs at KSF.
Physicians can access data from computers at satellite locations. “We are working on
access with PDAs [portable data assistants]
or hand-held devices,” says Malik.
What Is Next?
“We wanted a seamless program to do a
few things as quickly as possible,” says
Berkowitz. And he believes KSF has
succeeded in meeting that objective. “There
Transitioning from paper to electronic record keeping does not happen immediately. Training medical professionals and transferring existing records takes time.
KSF Orthopaedic Center
11
is a huge integration that needs to go on,” he explains. “What Dr.
Cuellar is trying to do is develop new processes.”
When the full potential of EMRs is realized at KSF, patients
will benefit in multiple
ways. Continuity and
coordination of care will
be more transparent.
EMRs also make it easier
for physicians to send
reminders and education
materials to patients.
They also ensure that
patient follow-up is done
on schedule.
Physicians can enter data directly via a
Because EMRs can
keyboard or by voice.
link to guidelines and
documentation tools, they
simplify the access physicians routinely seek to the changes in treatment protocols and documentation requirements of regulatory
agencies and bodies.
There is a learning curve with any large-scale change in a practice,
especially one of such magnitude. “This is a huge project,” says
Berkowitz. “In the 15 years I have been here, nothing can match changing to electronic medical records in terms of commitment required.”
But being ahead of the curve in health care, doing whatever it
takes to put patients first, is part of the philosophy of KSF. So
making the commitment to invest wholeheartedly in EMRs was
something all the physicians at KSF agreed on quickly. OE
12
Orthopaedic Excellence
New Web Site Designed with Patients
in Mind
As part of KSF Orthopaedic Center’s commitment to its
patients, the group built a new Web site that went live in
January 2006 to help integrate the wealth of information available to patients. The site has downloadable forms so patients
can have them filled out and ready before they even get to the
office, greatly decreasing the wait time at the office.
There is also a section to schedule appointments online. “The
new Web site was designed with the patient in mind; it was
built to incorporate all the various facets that make KSF a complete orthopaedic care facility and to help educate patients on
common orthopaedic problems,” says Aaron Kant, Marketing
Director for KSF.
The Web site will
continue to grow,
with more information added every
month. Patients can
visit the Web site at
www.ksfortho.com. If
patients have specific
questions, they can
e-mail KSF through
the Web site as well.
KSF Orthopaedic Center
13
One Practice,
Many Services
KSF Orthopaedic Center Guides Patients
from Diagnosis to Rehabilitation
T
he physicians and staff at KSF
Orthopaedic Center don’t want their
patients to “break their backs”
searching for diagnostic facilities, the perfect
surgical unit, or a competent physical therapist. By handling diagnostic testing, physician visits, surgery, and rehabilitation, KSF is
a one-stop destination for orthopaedic
needs. Physicians in the practice are board
certified or board eligible and have fellowships in specialties that include joint replacement and surgery of the hand, elbow, shoulder, foot, ankle, knee, and spine.
Three physicians formed the original
backbone of the practice. Andrew Kant, MD,
the “K” in KSF, is a board-certified
orthopaedic surgeon who specializes in treating spinal problems and injuries. He founded
KSF in 1976 to bring high-quality orthopedic
care to the residents of Northwest Houston
and the Woodlands areas.
“I chose orthopaedics because you get
to work with people of all ages, from newborns to seniors,” says Dr. Kant. He also
chose this field because patients’ lives are
improved after treatment. “We can usually
fix what is wrong, restoring their ability to
KSF Orthopaedic Center is equipped to take patients through the whole spectrum of orthopaedic care, from diagnosis to treatment and rehabilitation.
14
Orthopaedic Excellence
walk or play with their children or grandchildren,” he explains.
Dr. Kant is a past president of the
Houston Orthopaedic Society and has
served as president of the medical staff and
chairman of the Department of Surgery at
Houston Northwest Medical Center. He
currently serves as President of the Texas
Orthopaedic Association.
Dr. Kant is impressed with the technological advances that have made surgery less
invasive with shorter recovery times. He
notes that KSF was one of the first
orthopaedic groups in Houston to use
arthroscopy. Improved treatment of spinal
problems and injuries also promises patients
a more positive future. “A lot of what I can
offer patients today didn’t exist when I
finished training,” he explains. “We have
better materials and techniques. It is really
phenomenal, and it continues to change.”
“I like to sit down with my
patients and listen carefully to what is bothering
them and gain an understanding of what they want
to achieve. I then do a
detailed examination and
work with them to decide on
a treatment plan that best
suits their personal needs.”
— Mark A. Stuart, MD
Beginnings
Dr. Kant was soon joined by Mark A.
Stuart, MD, (the “S” in KSF) a native of
South Africa who specializes in arthroscopic
surgery of the knee and shoulder. Dr. Stuart,
who was inspired to pursue orthopaedic surgery by his father, a general practitioner,
spends time finding out about his patients.
“I like to sit down with my patients and
listen carefully to what is bothering them
and gain an understanding of what they
want to achieve,” says Dr. Stuart. “I then do
a detailed examination and work with them
to decide on a treatment plan that best suits
their personal needs.”
Dr. Stuart is a
member of the
Arthroscopy Association of North
America, the Texas
Sports Medicine
S o c i e t y, t h e
Houston Orthopaedic Society, the
American Academy
of Orthopaedic
Surgeons, the Texas
Orthopaedic
Society, the Harris
County Medical
Society, and the
Te x a s M e d i c a l
Association.
Ray M. Fitzgerald, MD, a
native Houstonian
who joined the
practice after meeting Drs. Kant and
Stuart, was particularly interested in
practicing in
Northwest Houston. He is a member of the American
Medical AssoPhysicians at KSF Orthopaedic Center provide patients with one-on-one attenciation, the Texas
tion in order to make a complete diagnosis and treatment plan.
Medical Association, the Harris County Medical Society, the Commission on Certification of PAs in conTexas Orthopaedic Association, the junction with the National Board of Medical
Houston Orthopaedic Society, the Amer- Examiners. To maintain their national certifiican Academy of Orthopaedic Surgeons, the cation, PAs must log 100 hours of continuing
Alamo Orthopaedic Society, the Texas medical education every two years and sit
Society of Sports Medicine, the Inter- for a recertification every six years.
Physician assistant-certified (PA-C)
national Arthroscopy Association, and the
Arthroscopy Association of North America. means the person has completed the defined
Dr. Fitzgerald focuses on knee and shoul- course of study and has undergone testing
der problems involving the cartilage and b y t h e N a t i o n a l C o m m i s s i o n o n
rotator cuff and has a special interest in Certification of Physician Assistants
arthroscopic surgery of the knee and shoul- (NCCPA), an independent organization,
der. Like these three charter members, all composed of commissioners representing a
physicians at KSF have the knowledge and number of different medical professions.
technical support to care for patients from
Onsite Diagnostics
diagnosis to recovery.
Onsite diagnostic equipment increases
the physicians’ diagnostic capabilities by
Physician Assistants
Besides the physicians, KSF’s seven providing an inside view of injured bones
physician assistants (PAs) are trained in and tissues. Besides traditional x-ray and
intensive education programs accredited by electromyogram (EMG) technology, KSF
the Accreditation Review Commission on offers on-site magnetic resonance imaging
Education for the Physician Assistant (MRIs), an important diagnostic tool for
(ARC-PA). PAs take a national certification orthopaedists. Generating detailed views of
examination developed by the National soft tissue such as tendons and muscles, as
KSF Orthopaedic Center
15
well as hard tissue structures such as bones,
without radiation, the MRI displays internal
structures in thin cross-sections or in 3-D,
permitting a physician to view an injury or
disease condition from many angles.
The intricate information gathered from
MRI examinations removes the guesswork
from the diagnostic process, allowing physicians to develop accurate and effective treatment plans. When choosing the right MRI
for the practice, physicians elected to offer
the new “open” MRI machine to help
patients who are uncomfortable when in
enclosed spaces, as well as larger patients
who may have trouble fitting into a closed
MRI. KSF is adding a second MRI machine
so it can serve patients even more efficiently.
Another diagnostic tool, the bone mineral densitometer, checks for bone mineral loss
to detect which patients are at risk for osteoporosis or are osteopenic (have decreased
bone density). The bone densitometer uses
low amounts of x-rays to produce images of
the spine and hip area. Then a computer is
used to achieve results defined by what the
World Health Organization considers normal among different age groups. This score,
along with other factors, helps physicians
gauge the risk of an osteoporatic fracture or
the need for medication.
Treatment Options
If surgery is indicated, the KSF
Orthopaedic Surgery Center continues the
personalized care program that is paramount at KSF’s other divisions. KSF
Orthopaedic Surgery Center was the first
ambulatory surgery center in Houston dedicated entirely to orthopaedics. The center’s
friendly staff, easy access, ample parking,
and degree of personal attention far exceed
the consideration a patient receives in a
hospital environment.
The center’s three surgical suites were
designed and equipped especially for the
care of orthopaedic patients. State-of-the-art
arthroscopic video equipment allows the
surgeons to provide the best care with the
least invasive techniques. KSF’s surgeons are
also affiliated with Willowbrook Methodist
Hospital, Houston Northwest Medical
Center, and the TOPS Surgery Center.
After surgery or an injury, KSF’s 10,000square-foot Sports Medicine and Physical
Therapy Center takes over with 13 boardcertified or board-eligible physicians, five
full-time licensed physical therapists, and
three full-time occupational therapists, one
of whom is a hand therapist, in addition to
three technicians. The therapy facility is
equipped with the most modern rehabilitation and exercise equipment, as well as cardiovascular equipment that includes recumbent bicycles, elliptical machines, stair
climbers, upper-arm bicycles, and treadmills.
A whirlpool assists with treatment for
injuries in the hand, elbow, and lower leg.
The close connection between therapists
and KSF’s orthopaedic physicians allows for
convenient communication and more efficient treatment planning. When patients
walk into the offices at KSF, they have the
comfort of knowing that the team will
provide comprehensive care from diagnosis
to rehabilitation. OE
Making It Easy — On-Site MRI Simplifies and Speeds Diagnostic Process
By Nancy Chiczewski
KSF Orthopaedic Center’s MRI Department
opened its doors to all KSF patients in
1998. With KSF’s GE Profile Open concept
system, MRI exams are performed in a large
magnet opening with a wide, padded table
for complete patient comfort. The MRI room
has a wall of windows that allows plenty of
sunlight to enter the room and adds to the
feeling of openness and brightness.
Patient safety and
comfort are key concerns of all KSF staff,
and every effort is
made to ensure
patients are comfortable and relaxed
before, during, and
after MRI exams.
MRI exams are scheduled as early as
6:45 a.m., with the last appointment taken
at 5:45 p.m., Mondays through Saturdays
and occasionally on Sundays. This allows
patients to spend less time away from their
jobs, school, or other activities and promotes patient convenience. We strive to
have all patients schedule their MRI scans
at KSF within three working days. Should
the wait time exceed three working days,
additional night and/or Sunday appointments are provided as needed.
KSF is one of the
few orthopaedic
groups in the country
that have an MRI
Department fully
owned and on-site for
the exclusive use of
its patients. This MRI of back showing a herniated disc
allows for faster
process in 1998. This rigorous process must
scheduling times, on-time appointments,
be reviewed daily and renewed every three
group-specific techniques, and shortened
years to ensure excellent image quality.
result-waiting times.
The MRI Department is staffed by trained,
nationally certified MRI technologists with a
combined experience of more than 30 years.
The American College of Radiology (ACR)
has accredited the KSF magnet system since
the inception of the ACR standardization
16
Orthopaedic Excellence
For more information regarding the MRI
Department at KSF Orthopaedic Center, call
(281) 880-1451.
Strong
Bones
for Life
Preventing, Treating Osteoporosis
Improves Life After 50
BY RAUL SEPULVEDA, MD, AND SAMUEL ALIANELL, MD
I
t’s called a silent disease because those who have it often don’t
know — until it is too late. Osteoporosis, or “porous bone,” causes an estimated 1.5 million fractures among Americans every
year. According to Raul Sepulveda, MD, at KSF Orthopaedic
Center, osteoporosis becomes evident only when a small impact (or
even no impact) causes a bone fracture that otherwise would not
have occurred.
“Osteoporosis is like high blood pressure, another silent
disease, in that people often do not know they have it,” says Dr.
Sepulveda. “A person may not be aware of high blood pressure until
a stroke or heart attack happens. A woman may not know she has
osteoporosis until she mysteriously falls to the floor from a simple
standing position.”
In the last decade, treatment and prevention of osteoporosis
have risen to the forefront of women’s health concerns. While it
affects both genders, women tend to have lighter bone mass than
men from the start. And menopause and hormonal changes speed
bone loss. Fortunately, researchers and health care professionals
report significant strides in reducing its consequences.
One of the newest and most accurate tools for determining if a
person has osteoporosis or is at risk is bone densitometry testing.
While there are different techniques for measuring bone density, the
“gold standard” method is called dual energy x-ray absorptiometry
(DEXA). The test uses a weak form of x-ray to measure bone
mineral density.
“Fragility fractures typically occur in the spine, hip, or forearm,
so that is where the DEXA scans are focused,” says Dr. Sepulveda,
noting that the test takes only a few minutes and involves no shots
or medicine. Patients do not even have to disrobe, provided their
clothing contains no metal objects.
Not for Women Only
Throughout his medical career, Dr. Sepulveda has worked to
reduce the misunderstandings surrounding the disease. The belief
KSF Orthopaedic Center
17
that only women are affected is one of the
biggest misconceptions. In fact, 25% of men
age 50 and older will have an osteoporosisrelated fracture during their lifetimes.
Given that the disease affects both genders, a DEXA scan is important for everyone.
All women age 65 or older and all men age
70 or older should be tested at least once and
perhaps more often if the initial test shows
bone loss or individual circumstances require
it, says Dr. Sepulveda. He adds that the
so-called dowager’s hump (see article on
page 19) that some women develop later in
life may flag the condition.
Experts recommend that anyone with a
fragility fracture (regardless of age) also have
the test, as well as women who have not been
on hormone replacement therapy for prolonged periods. “If osteoporosis is detected
and a patient goes on medication, a test may
be required as often as every six months to
one year to monitor therapy and, if bone
density has stabilized with follow-up testing,
every two years, “ says Sam Alianell, MD, a
physiatrist (physical medicine and rehabilitation specialist) who also manages osteoporosis at KSF.
Osteoporosis Facts
• Osteoporosis is a major public health
threat for an estimated 44 million
Americans, or 55% of people age 50
and older.
• In the United States, 10 million people
are estimated to already have the disease, and nearly 34 million more are
estimated to have low bone mass, which
puts them at risk for osteoporosis.
• One in two women and one in four men
older than age 50 will have an osteoporosis-related fracture in his or her
remaining lifetime.
• Women can lose up to 20% of their
bone mass in the five to seven years
following menopause, making them
more susceptible.
• Significant risk has been reported in
people of all ethnic backgrounds.
• Osteoporosis is responsible for more
than 1.5 million fractures annually,
including more than 300,000 hip fractures, approximately 700,000 vertebral
fractures, and 250,000 wrist fractures.
18
Orthopaedic Excellence
This x-ray shows a degenerating hip.
The U.S. Food and Drug Administration
has approved several medications to treat
osteoporosis, including Fosamax®, Actonel®,
and Boniva®. These are taken either daily,
weekly, or monthly and are usually effective
and well tolerated. Other medications such
as those with the brand names Miacalcin®,
Forteo®, and Evista® are also approved.
Dr. Alianell prescribes these medications
according to the individual needs and circumstances of the patient.
Theses medications are aimed at both
prevention and treatment of osteoporosis or
for certain varieties of the disease. A new
genetically engineered parathyroid hormone
can also be used when all other measures
have failed.
Nutrition and Exercise
Like many diseases, preventive measures
early in life can mean better health
later. Bone mass is at its peak and strongest
when people are in their mid-30s, notes
Dr. Sepulveda.
Good nutrition with plenty of calcium
and regular exercise go a long way toward
protecting joints and preventing osteoporosis before it starts. Individuals should
consume 1200 to 1500 mg. of elemental
calcium a day in addition to 400 to 800 units
daily of vitamin D. A regular program of
weight-bearing exercise is also important as
a means of compensating for bone loss and
reducing the likelihood of fragility fractures
in later years.
The utilization of some medications,
such as prednisone (steroid) and those for
seizures, may increase bone loss. Other risk
factors include being older than 70 years of
age, smoking, not consuming enough calcium-rich foods, and having a family history
of osteoporosis or bone fractures.
“Once an older person has a hip or spine
fracture, other health problems often get
worse,” says Dr. Sepulveda. “His or her independence diminishes, and a fair number end
up in nursing homes.” He also notes that prevention success stories “are in the absence of
fractures, which we do not hear about.”
Dr. Alianell concurs with Dr. Sepulveda.
“Diet and exercise — particularly resistive
exercise, thoracic/lumbar extension, and
pectoral stretching — as well as education
on posture and body mechanics, are very
helpful in managing osteoporosis.”
And if progress in the past is any indicator, the future looks bright for attempting to
prevent the suffering osteoporosis causes.
“When I first started out in medicine, osteoporosis was considered a normal part of
aging,” says Dr. Sepulveda. “As our understanding has increased, DEXA scanners and
new medicines became available. It has been
a huge leap forward in the diagnosis, treatment, and prevention of the disease.” OE
Raul Sepulveda, MD, a boardcertified neurosurgeon, earned
his medical degree from
Universidad Nuevo Leon in
Monterrey, Mexico, where he also
completed his internship. He
completed a one-year residency
in general surgery at the Miami
Valley Hospital in Dayton, Ohio, and a neurosurgery
residency at Henry Ford Hospital in Detroit, Michigan.
Dr. Sepulveda has served as President of the Medical
Staff and Chairman of the Department of Surgery at
Houston Northwest Medical Center.
Samuel Alianell, MD, graduated
from the State University of New
York at Buffalo and earned his
medical degree at the State
University of New York Health
Science Center at Syracuse. He
completed his internal medicine
internship and physical medicine
and rehabilitation residency programs at Loma Linda
University Medical Center in Loma Linda, California.
He is a Diplomat of the American Board of Physical
Medicine and Rehabilitation and the American Board
of Electrodiagnostic.
e
h
t
C
u
g
rve
n
i
Straight en
Kyphoplasty Restores
Spine Height, Shape
BY RAUL SEPULVEDA, MD, AND SAMUEL ALIANELL, MD
V
ertebral compression fractures in
patients with osteoporosis usually
produce severe pain. Because of the
loss of height of the vertebra, these fractures
may produce changes in the curvature of the
spine called kyphosis, or “dowager’s hump.”
The patient usually becomes shorter in
stature. The spinal deformity, pain, impaired
function, and decreased mobility can actually
The left image shows a normal spine, while the
image on the right illustrates the curvature of the
spine called kyphosis.
lead to more bone
loss. Depending
on the locations of the
fractures,
shortness of
breath can
also result.
This is due to
diminution in
Normal vertebra
the chest size.
Due to the severity of the symptoms, some patients become
increasingly dependent upon others. After
the first vertebral compression fracture
occurs, the risk of subsequent fractures is
increased. Therefore, it is ideal to try to prevent osteoporosis and, if it develops, to treat
it with proper exercise, diet, smoking cessation, and medication when necessary.
In patients who develop vertebral fractures that are not treatable with conservative
measures, we have the option of a minimally invasive procedure call kyphoplasty,
in which inflatable bone tamps are introduced into the vertebral bodies. Once
inflated, the bone tamps at least partially
restore the vertebral body back to its
Fractured vertebra
original height and create a cavity that can
be filled with bone cement.
Frequently, this is very helpful in partially alleviating pain and also helping reduce
fractures. The procedure diminishes the loss
of spinal curvature and helps prevent the formation of the dowager’s hump. More than
17,000 kyphoplasty procedures have been
performed nationally and internationally
over the last several years. OE
The Kyphoplasty Procedure At a Glance
IBT close-up
IBT inserted
IBT inflated
IBT withdrawn
KSF Orthopaedic Center
19
The Truth
About
Total Knee
Replacements
O
ften, when people hear of knee
replacement surgery, they believe
the entire knee is replaced. This is a
common misconception. The surgery is
actually considered a resurfacing procedure.
That is, the diseased surfaces of the joint are
shaved off and replaced with durable metals
and plastic.
Because our knees are subjected to large
forces everyday, the cartilage in the knee can
wear out over time. When we walk, twice
our body weight is put on the knee with
every step. If we participate in sports, fall, or
injure the knee, changes can occur in the
smooth cartilage surface and may ultimately
result in a painful arthritic knee. In some
cases, people can develop strong inflammation in the joint that can destroy cartilage,
causing arthritis.
Surgical Procedure
Repairs the Knee
Rather than
Replaces It
ligament (PCL) is removed, depending on
the type of prosthesis and the nature of
the pathology.
20
Orthopaedic Excellence
A few millimeters of the upper end of
the tibia (shinbone), along with meniscal
cartilage, are removed. The top of the tibia
is covered with a metal plate that holds a
very durable plastic called polyethylene.
The highly polished femoral implant rolls
and glides over the plastic insert, mimicking
the action of a normal knee joint. In
approximately two-thirds of the cases, the
undersurface of the kneecap is also removed,
and a piece of plastic is used to reline the
undersurface of the kneecap. The kneecap
itself remains in place.
Pain Relief and Greater Mobility
A Joint Makeover
A total knee replacement resurfaces
the bone. During the surgery, a few
millimeters of the end of the femur (thighbone) are removed and replaced with a
metal cap. In this operation, the anterior
cruciate ligament (ACL) is removed,
and sometimes the posterior cruciate
BY ALBERT D. CUELLAR, MD
Most knee replacements have four parts — the
femoral component, fitted on the end of the thigh
bone; the tibial component, attached to the top of
the shin; the patellar component, a plastic replacement for cartilage underneath the kneecap; and a
plastic insert, which is placed between the femoral
and tibial components.
In general, approximately 90% of
patients with total knee replacements experience pain relief. After surgery, patients will
still have most of their original ligaments,
muscles, and tendons. By the time most
patients come to realize they might need a
total knee replacement, they have already
had muscle atrophy or breakdown because
of the inability to walk, stand, climb, or
exercise. Patients might also have stiffness
of the ligaments because of loss of motion
or the loss of the ability to straighten or
bend the knee.
Conditions
Requiring a TKA
The following symptoms may indicate a
need for TKA:
• Severe knee pain that limits everyday
activities, including walking, going up
and down stairs, and getting in and
out of chairs
• Moderate or severe knee pain while
resting, either day or night
• Chronic knee inflammation and
swelling that doesn't improve with
rest or medications
• Knee deformity — a bowing in or out
of the knee or stiffness —- and the
inability to bend and straighten the
knee
• Failure to obtain pain relief from nonsteroidal, anti-inflammatory drugs
Also, knee arthritis can cause limb deformities such as bowlegs and knock-knees.
Knee replacement surgery typically corrects
these deformities. Arthritis of the knees is
often accompanied by irritation around the
soft tissues. When the knee is resurfaced in a
total knee replacement, you will still have
these original structures, which will need to
be rehabilitated.
In general, approximately
90% of patients with total
knee replacements experience pain relief.
The prosthesis will allow full extension
and often flexion to 125 degrees. The range
of motion a patient recovers depends a great
deal on how well that person can tolerate
and participate in the rehabilitation program
in order to achieve extension and flexion. In
general, knees that are replaced will last 15
to 20 years.
Heavier individuals tend to have more
difficulty simply because there is more tissue
around the knee, and they also tend to
have more bleeding. If a patient with a
severe arthritic knee waits a long time to
have the procedure, there can sometimes be
permanent joint deformities that will not
allow full motion.
Total knee replacements are very cost
effective. Various studies have shown that a
knee replacement can save up to $50,000 or
more in lifetime health care expenses
because of less need for custodial and nursing home care.
Alternative Treatment Regimens
Total knee arthroplasty is the final stage
in the treatment of knee arthritis. Initially,
the treatment is weight loss and an exercise
program to strengthen the muscles that support the knee. Acetaminophen can be used
to relieve pain. Over-the-counter antiinflammatory medications such as Motrin®
or Aleve®, when indicated, can also be used.
There are other prescription medications
that are helpful as well. Cortisone can be
injected in the joint to help with pain and
inflammation. There are also other types
of medications that can be injected into the
knee to try and ease the pain, discomfort,
and stiffness of arthritis.
Ultimately, patients with severe, persistent pain in their knees who have not had
significant relief with other measures may
consider knee replacement. OE
Albert D. Cuellar, MD, is a boardcertified orthopaedic surgeon.
He graduated magna cum laude
from Texas A & M University with
a degree in bioengineering. He
went on to medical school at the
University of Texas Medical
Branch (UTMB) in Galveston,
where he also completed his internship in general
surgery and his residency in orthopaedic surgery. Dr.
Cuellar also completed a preceptorship and one-year
fellowship in adult joint reconstruction at Presbyterian
Hospital/Southwestern Medical School in Dallas.
Patient Home Preparation
There are several actions you can take
before knee replacement surgery to facilitate your recovery, including preparing your
home. Making your home as comfortable
— and as safe — as possible can ease
much of the discomfort and prevent many
of the hazards that come with surgery
recovery. Here are some home-preparation
ideas to make your home easier to navigate
after surgery.
• Prepare a temporary living space on the
main floor to avoid using stairs during
your early recovery.
• Install secure handrails along stairways
for long-term recovery.
• Install secure handrails as well as
a stable bench or chair in showers
or baths.
• Obtain a stable chair with a firm seat
cushion and back, two armrests, and
a footstool for periodic leg elevation.
• If you have pets, arrange for a family
member or friend to “pet sit” or board
your pets at a local veterinary office or
pet store.
• Arrange furniture to allow mobility with
a walker.
• Make sure hard-to-reach objects,
as well as regularly used items such
as a phone and medications, are
easily accessible.
• Prepare and freeze meals before
surgery or arrange for someone to
help you at mealtimes.
• Make plans for someone to run your
errands and drive you to appointments.
Alternatively, you can arrange for a short
stay at an extended-care facility during
recovery to ensure you have help
at hand and prevent changing your
home atmosphere.
• Remove all loose carpets, cords, and
other obstacles that could cause you
to fall.
KSF Orthopaedic Center
21
Pinpointing the Pain
Shoulder Issues Often Related to Rotator Cuff Degeneration or Injury
BY MICHAEL S. GEORGE, MD
R
otator cuff tears are a common cause
of shoulder pain. The rotator cuff is a
group of four tendons that originate
on the scapula and insert on the proximal
humerus that act to rotate and elevate the
shoulder. When functioning normally, the
rotator cuff depresses the humeral head
away from the acromion.
Causes and Symptoms
The most common tear of the rotator
cuff is an avulsion of the supraspinatus tendon from the greater tuberosity. These
injuries are often caused by acute traumatic
injuries such as a fall on the outstretched arm
22
Orthopaedic Excellence
or a traumatic glenohumeral dislocation.
Chronic degenerative tears occur with
overuse and are often associated with subacromial bursitis and bone spurs on the
undersurface of the anterior acromion. Tears
or dysfunction of the rotator cuff decrease
the ability to rotate and depress the humeral
head, causing weakness and pain.
Rotator cuff tears typically cause pain
with overhead motion and frequently wake
patients up from sleep when they lie on the
affected shoulder. Clinical signs of rotator
cuff tears include weakness with shoulder
movement, pain with passive forward flexion, and internal rotation of the shoulder.
Frequently, chronic rotator cuff dysfunction is associated with arthritic changes
of the acromioclavicular joint that may
be elicited clinically by tenderness on
the joint and pain with passive adduction of
the shoulder.
Diagnosis and Treatment
Plain radiographs are useful to detect
acute fractures or dislocations, arthritic
disorders, and calcific tendonitis. Humeralhead elevation can indicate a large, retracted
tear. Chronic retracted tears can eventually
result in rotator cuff arthropathy, arthritic
degeneration of the glenohumeral joint with
articulation and wear of the humeral head on
the acromion above it. MRI is a very useful
diagnostic tool, displaying tears of the
rotator cuff tendons as well as atrophy of
the muscles and other shoulder disorders.
Conservative treatment may be successful with chronic degenerative tears in lowdemand or elderly patients. Although the
torn tendons rarely heal spontaneously,
exercises aimed at strengthening the intact
portions of the rotator cuff can alleviate the
pain due to rotator cuff dysfunction.
Subacromial steroid injections may relieve
the pain associated with subacromial bursitis, allowing physical therapy to be effective.
Rotator cuff disorders may begin with abrasion,
bleeding, and swelling that can lead to a cycle of
inflammation and damage. Over time, scar tissue
replaces healthy tendon tissue, and the tendons
become stiff, stringy, and more fragile.
Surgical intervention may be warranted
when conservative management fails or in
the case of an acute rotator cuff tear.
Historically, open rotator cuff repair yields
very good results. New techniques have
eliminated the need for violation of the deltoid insertion, resulting in faster recovery
and less postoperative pain.
Shoulder arthroscopy allows direct
visualization of the rotator cuff as well as
other shoulder lesions. Subacromial decompression is performed to debride painful
bursa and scar tissue as well as permit
adequate visualization of the superior surface
of the rotator cuff. Arthroscopic acromioplasty removes bone spurs on the undersurface of the anterior acromion. Arthritic
pain of the acromioclavicular joint may
also be addressed by arthroscopic or open
excision of the distal clavicle.
Rotator cuff repair is now performed
either arthroscopically or via a “mini-open”
Treating SLAP Lesions
When you think of a ball-and-socket joint,
the hip joint springs to mind — a large ball
completely seated into a deep conforming
socket in the pelvis. While this type of joint
is great for walking, it doesn't meet the
tremendous range of movement needed by
the shoulder to position the hand in the
many ways we use our arms each day.
To solve this range-of-motion need, the
shoulder is constructed more like a ball on
a saucer — a large ball on a very flat socket with just enough lip to keep the ball centered in proper position. The socket, which
is part of the scapula, is modest in size. A
coating of hyaline cartilage augments the
depression in the scapula. That cartilage is
then surrounded by more fibrous tissue,
the glenoid labrum.
A tendon from the biceps muscle inserts on
the labrum. The biceps tendon can fray or
tear, as can the labrum. When either condition occurs, the resulting injury is called
a superior labral tear from anterior to posterior (SLAP) lesion. Such tears occur with
trauma to the joint or with repetitive
actions like throwing or overhead use,
resulting in pain.
approach. Mini-open repair involves an
approximately 4- to 6-cm incision with
minimal dissection through the deltoid muscle. The recently developed arthroscopic
repair procedure does not disturb the deltoid
muscle and is performed through several
percutaneous incisions. The rotator cuff is
reattached to the greater tuberosity, using
heavy nonabsorbable sutures through transosseous tunnels or preloaded suture anchors.
Chronic, severely retracted rotator cuff
tears are occasionally irreparable. In some
cases, surgical debridement of the torn edges
of the tendon has yielded adequate results.
Latissimus dorsi tendon transfers have had
mixed results based on related literature.
When chronic tears result in rotator cuff
arthropathy, shoulder arthroplasty using a
hemiarthroplasty prosthesis or the new
reverse-ball-and-socket prosthesis has
shown very promising outcomes.
Recovery and Rehabilitation
Postoperatively, passive range of motion
physical therapy begins immediately. Active
Lateral view of the glenoid cavity
A SLAP lesion seldom heals on its own.
Frequently, surgery is required, followed by
a physical therapy program. Some conditions may be simply trimmed; others
require reattachment of the labrum to the
socket using a variety of anchors or tacks.
Still others require stabilization of the
biceps tendon to the ball, removing the
biceps
from
the
joint
entirely.
Rehabilitation after surgery aids in reducing pain and inflammation, restoring range
of motion, strengthening tissues, and
improving joint stability.
range of motion is started at three to six
weeks, depending on the size of the repair.
Long-term results of rotator cuff repairs have
been excellent. Innovative arthroscopic
techniques are continuing to advance the
successful treatment of rotator cuff tears.
KSF can provide comprehensive care for
all variations of shoulder injuries and rotator
cuff tears with new treatments that reduce
invasiveness, pain, and recovery time. OE
Michael S. George, MD, graduated Magna Cum Laude from
Case Western Reserve University
in Cleveland, Ohio, where he also
played linebacker on the football
team. He earned his medical
degree at Case Western Reserve
University and later completed
his orthopaedic surgery residency training at the
University of Cincinnati. Dr. George went on to obtain
additional fellowship training in orthopaedic sports
medicine and shoulder surgery at Vanderbilt
University, where he gained extensive experience in
advanced shoulder and knee surgery.
KSF Orthopaedic Center
23
Getting Back
to
Life
KSF
Sports
Medicine and
Physical Therapy
Center Helps
Patients Recover, Thrive
W
hatever the cause, an injury to
the spine or joints is life altering.
The patient’s body does not feel
or move the same, and the pain involved in
many orthopaedic injuries is often excruciating. After an injury or invasive surgery
derails a patient’s life, the KSF Sports
Medicine and Physical Therapy Center at
KSF Orthopaedic Center, P.A., helps the
patient get back to business.
The 28-year-old center is state of the art,
with a 10,000-square-foot facility available
to patients in Houston and the surrounding
areas. It is staffed by 13 board-certified or
board-eligible physicians, five full-time
licensed physical therapists, and three fulltime occupational therapists, one of whom is
a hand therapist, as well as three technicians,
four physical therapist assistants, and one
occupational therapist assistant.
Rehabilitative Therapy
Physicians refer patients to the center
for diverse conditions. According to Alicia
Walker, PT-C, Clinic Supervisor for the
24
Orthopaedic Excellence
While some patients are assigned weeks or months of care at the center,
others only need one session to learn customized home exercise programs.
Sports Medicine Department, patients run
the gamut. Clinic physicians are adept at
treating numerous orthopaedic conditions,
including rotator cuff injuries, impingement
syndrome, bursitis, and knee injuries such as
preoperative and postoperative ACL reconstructions and meniscus tears. “We treat
everything from sprains and strains, neck
“We treat everything from
sprains and strains, neck
pain, back pain, and
cervical radiculopathy (a
problem in the neck that
sends pain down the arm)
to torn Achilles tendons.”
— Alicia Walker, PT-C, Clinic Supervisor for
the Sports Medicine Department
pain, back pain, and cervical radiculopathy
(a problem in the neck that sends pain
down the arm) to torn Achilles tendons,”
says Walker.
Before a therapy regimen is developed,
patients receive referrals from their physicians. Since the facility is owned and operated by KSF Orthopaedic Center, therapists
can work closely with board-certified
orthopaedic surgeons, allowing for easy
communication between all parties involved
in a patient’s case. An electronic medical
record (EMR) system allows the physical
therapists and physicians access to patients’
MRIs and reports. Before implementing the
EMR system, physicians and therapists relied
on transporting paper files between the
medical office and the therapy center.
During the initial evaluation, the therapist administers a battery of tests that takes
approximately one hour. “We check limits,
strength, and pain level, and then we establish a plan of care,” says Walker. The written
plan allows each staff member to understand
what level the patient has reached and what
protocol to follow. “For example, rotator
cuffs are only movable to a certain degree,
and physicians have their preferences,”
says Walker.
Physical therapists are licensed to perform the evaluations, after which both physical therapists and physical therapy assistants
follow the plan of care. While some patients
are assigned weeks or months of care at the
center, others need only one session to learn
customized home exercise programs.
The center also is equipped with a
whirlpool that allows therapists to perform
wound care for the hand, elbow, and lower
leg. “In the whirlpool, occupational therapists help patients who have severed tendons
or sustained wounds,” says Walker. Water
with added medication helps flush out the
infected area and stimulates healing.
Patient Involvement
Equipment and Techniques
The center is equipped with the latest
Cybex® rehabilitation and exercise equipment, as well as cardiovascular equipment
such as recumbent bicycles, EFX, a stair
climber, an upper-arm bicycle, and treadmills.
“The stationary bikes improve a knee patient’s
range of motion,” says Walker. “When they
arrive, they usually cannot even make a full
revolution. But after a while, when they can
make a full revolution, the bike becomes more
of a cardiovascular exercise.”
Back patients who cannot walk or stand
for long periods of time are steered toward
the stationary bike, while treadmills ease
the difficulty of standing or walking. “The
Recovery outcomes are improved when patients
take active roles in their own therapy programs.
treadmill moves at a steady pace, which
improves gait and eliminates limps,” says
Walker. “Patients can also lean on the
handrails to take pressure off their knees. The
EFX elliptical machine resembles jogging or
walking without the pounding force. And for
higher-end athletes, the simulation of walking
or running addresses endurance issues.”
Physical therapy is a resource many
physicians rely on daily to provide a higher
level of service to their patients, and it is an
opportunity for patients to receive help in
their recoveries. The physicians of KSF
Orthopaedic Center and the physical therapists of the KSF Sports Medicine and
Physical Therapy Center take a team
approach to patient recovery, and they know
the patient is an important member of that
team. Encouraging patients to become active
and involved in their recoveries can improve
the outcomes.
Through this team approach, the center
uses exercise and rehabilitative techniques to
help patients with orthopaedic injuries or
recovering from surgery improve the quality
of their lives. OE
KSF Orthopaedic Center
25
Directory
KSF Orthopaedic Center thanks the following companies
for helping make this publication possible.
Banking
Republic National Bank
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see
page 9
Bracing & Prosthetics
TMC Orthopedic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see page 25
Cardiologists
Woodlands North Houston
Heart Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see inside back cover
Copiers
Office Systems of Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see page 12
Copying & Printing
Pain Management
Kwik Kopy
1010 Spring Cypress Rd.
Spring, TX 77373
(281) 353-7977
www.kkspring.com
Empi
River Oaks Pain Management
page 9
Memorial Hermann Home Health . . . . . . . . . . . . . . . . . . . see page 13
TOPS Surgical Specialty Hospital . . . . . . . . . . . . . . . . see back cover
Imaging
Champions MRI
14405 Walters Rd., Ste. A
Houston, TX 77014
(281) 397-6700 (281) 397-0099 Fax
River Oaks Imaging and Diagnostic
. . . . . . . . . . . . . . . . . see
page 13
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see
page 25
Insurance
Investment Management & Financial Counsel
Adell, Harriman & Carpenter . . . . . . . . . . . . . . . . . . . . . . . . . see page 12
Legal Counsel
Cohen & Small . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see page 12
Office Supplies
Stephens Office Supply, Inc.
7875 Northcourt Rd., Ste. 100
Houston, TX 77040
(713) 680-1616 (713) 681-8133 Fax
www.sosi-houston.com
Orthopaedics
DePuy Inc.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see
Stryker Orthopaedics
inside front cover
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see
page 26
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see
page 13
Orthopaedic Implants
Biomet, Inc.
26
Orthopaedic Excellence
. . . . . . . . . . . . . . . . . . . . . . . . . see
page 7
The Hand Rehabilitation Centers . . . . . . . . . . . . . . . . . . . . see page 25
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see
Benefit Secure
inside back cover
Physical Therapy & Occupational Rehabilitation
Health Care Services
HealthSouth
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see
Northeast Rehab Center
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see
Woodlands Sports Medicine Centre
. . . . . . see
page 13
inside back cover
KSF Orthopaedic Center, P.A.
17270 Red Oak Dr., Ste. 200
Houston, TX 77090