View Full Issue - St. Croix Orthopaedics
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View Full Issue - St. Croix Orthopaedics
ORTHOPAEDIC EXCELLENCE A publication from St. Croix Orthopaedics, PA 1991 Northwestern Avenue South Stillwater, MN 55082 (651) 439-8807 Phone (800) 423-1088 Toll free www.stcroixortho.com Additional Clinic Locations Lake Elmo, MN Woodbury, MN Maplewood, MN New Richmond, WI River Falls, WI Osceola, WI Baldwin, WI Hudson, WI Amery, WI Opening Remarks Welcome to the premier issue of Orthopaedic Excellence. We created this magazine to put high-quality, cost-effective orthopaedic information within patient reach — a goal St. Croix Orthopaedics (SCO) has consistently met during the 28 years since its founding. This publication is one more way to do just that. We hope you enjoy it. Orthopaedic Excellence will feature information on orthopaedic injuries and conditions, tested technology and techniques, as well as the physicians and staff that make it all happen. With 10 clinics and 17 physicians qualified in a variety of specialties, the depth of our knowledge and experience is broad, and we are proud to share it with you. As you turn the pages of this issue, read about the innovative procedures of artificial disc treatment for the spine and arthroscopic surgery for shoulder ailments and get new insights into common maladies like arthritis and carpal tunnel syndrome. Also relive the journey in Africa that an SCO physician and physician assistant took to provide orthopaedic care for a community in need. Robert Nuffort [email protected] Orthopaedic Excellence brings more than information and entertainment — it brings great opportunities for growth and change for both SCO and its patients. We look forward to presenting the latest orthopaedic trends and SCO news, and we also are interested in the content you want to see in this magazine. Feel free to let us know what you think, and please enjoy the magazine. Chief Operating Officer Sincerely, Chief Executive Officer Melanie Sullivan [email protected] Orthopaedic Excellence is an educational and informative resource for physicians, health care professionals, employer groups, and the general public. This magazine 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. 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) 4470911, 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]. Robert Nuffort, CEO 4 6 8 10 12 14 15 Optimism Abounds for Arthritis Sufferers Hip Replacement Surgery Can Add Stability to Your Step Shoulder Repair Arthroscopic Surgery Solves a Range of Ailments Call of the Wild St. Croix Orthopaedics Team Volunteers as Medical Missionaries in Africa Replacement Technology Moves to the Spine Artificial Disc Offers Alternative to Spinal Fusion If the Shoe Fits, Wear It Proper-Fitting Footwear Can Prevent Bunions Get a Grip Relief from Carpal Tunnel Syndrome Directory Orthopaedic Excellence 3 Optimism Abounds for Arthritis Sufferers Hip Replacement Surgery Can Add Stability to Your Step By Timothy J. Panek, MD G roin and/or thigh pain when walking, getting up from a chair, or even when sleeping could be signs of osteoarthritis of the hip. When the pain and stiffness in your hip keep you from engaging in daily activities, you may qualify as a candidate for total hip replacement. With the advances in orthopaedic surgery over the last decade, this is not as scary as it sounds. In fact, more than 180,000 people in the United States undergo hip replacement surgery each year to diminish pain and stiffness and regain full mobility. The most frequent source of debilitating hip pain is arthritis. In particular, osteoarthritis occurs primarily in people 60 years of age and older. In osteoarthritis, the layers of cartilage and synovial fluid become damaged and wear away, allowing the underlying bones to grind against each other. Hip replacement surgery is most commonly recommended when the severe, chronic pain associated with osteoarthritis is not controllable through the use of various medications or physical therapy. Conservative Treatment Before recommending total hip replacement, physicians usually try other forms of treatment, such as activity modification to reduce stress to the joint and/or a regular exercise program that includes stretching, swimming, or cycling to strengthen the muscles in the hip joint. Another option is to treat the inflammation in the hip with nonsteroidal anti-inflammatory drugs (NSAIDs). Common NSAIDs include aspirin, ibuprofen, and the COX-2 inhibitors, which block an enzyme known to cause an inflammatory response. Nutritional supplements such as glucosamine are also often helpful. If NSAIDs do not relieve pain, physicians may prescribe a corticosteroid, such as prednisone or cortisone. These drugs reduce joint inflammation and are frequently used to treat rheumatic diseases such as rheumatoid arthritis. However, their use is closely monitored, as they can cause further damage to the bones in the joint. Some people experience side effects such as increased appetite, weight gain, and a lower resistance to infections. Diagnosing Degenerative Hip Joints Hip replacement is usually considered only after conservative approaches have failed. The diagnosis of a degenerative hip joint starts with a complete history and physical examination by a physician. 4 St. Croix Orthopaedics Improved technology has made stronger, longer-lasting artificial joints that are feasible for more active and younger patients. X-rays are taken to determine the extent of the damage and the cause of the degenerative process. A magnetic resonance imaging (MRI) scan and blood tests are sometimes needed to rule out other causes. Once a recommendation for hip replacement is made, it is important for patients do their homework by investigating the issues, asking questions, and, most importantly, getting answers. Hip replacement was once an option primarily for less active adults 60 years of age and older, but improved technology has made stronger, longer-lasting artificial joints that are feasible for more active and younger patients. Younger patients and those who are more active should understand, however, that they might need another surgery to replace worn-out artificial hip joints after 15 or 20 years. Implant Durability Each patient should discuss with his or her physician two important questions: “What hip is right for me?” and “What approach will the surgeon use?” There are a variety of implant designs and materials. I consider the patient’s anatomy and physical demands when selecting the appropriate implant. I integrate all the advances in orthopaedic technology to help customize the implant for the patient. surfaces, making them much less likely to wear, which is the ultimate cause of total joint failure. A newer bearing-surface material, metal-onmetal, offers extremely low wear rates, which increases the joint’s longevity. Ceramic surfaces also offer low wear rates, but concern about implant fracture, squeaking implants, and potential difficulties if revision surgery is needed are all ongoing, unsolved issues. With the cemented implant, a steel ball on a stem is inserted into the bone to replace the femoral side of the joint, and a high-density, plastic socket replaces the acetabular side. Both of these components are secured to the bone with a self-curing, acrylic polymer (bone cement). On the plus side, cemented implants provide consistent pain relief due to immediate fixation and rapid recovery. However, the loosening rate of cemented acetabular components increases with time, leading to implant failure after 10 or 15 years. Implant Materials Another issue that needs consideration is the type of implant material to use. Metal-onplastic bearing surfaces have been used since the 1960s. Scientific advances in the plastic have improved these tried-and-true bearing After surgery, patients can expect pain relief and vastly improved function. Patients are generally advised to avoid certain activities such as jogging and high-impact sports. Usually, patients do not spend more than two to three days in the hospital after hip replacement surgery. Full recovery from the surgery takes approximately three to six months, depending on the type of surgery, the patient’s overall health, and the success of rehabilitation. Despite the large number of hip replacement operations performed each year in the United States, less than 10% require additional surgery. The most common problem that sometimes happens soon after hip replacement surgery is hip dislocation, which requires relocation and occasionally even reoperation. The key outcome is durability, which is dependent on the components used (materials, type, and preparation of the surfaces, as well as the design of the components), the technique, and the quality of fixation. It is also dependent on the patient’s activity level and the biological tissue reactivity, which varies. Cementless, press-fit implants are made of titanium and allow the patient’s bone to grow in and biologically “lock” the implant into place. In general, these devices are larger and longer than those used with cement, but they are proportional to the size of the individual bone. Complete pain relief after surgery is not as predictable with cementless implants as it is with cemented stems. Candidates for these devices are generally younger and more active than candidates for cemented application. approach is to make the smallest incision possible, while preserving the option to expand the incision if my exposure is compromising accurate and safe placement of the replacement components. A newer bearing-surface material, metalon-metal, offers extremely low wear rates, which increases the joint’s longevity. The most commonly used bearing-surface combinations in joint replacement today are metal or ceramic against ultra-high-molecular-weight polyethylene. These combinations have functioned well for most patients. Surgical Approaches and Results The final issue to consider from the surgeon’s perspective is incision size. The traditional 8-inch to 10-inch incision offers the advantage of excellent visualization, which allows for precise implant placement with reproducible and safe results for the patient. The drawback is a potentially more painful and prolonged recovery. The smaller, 3-inch to 6-inch minimal incision potentially offers less pain, shorter hospital stays, less muscle injury, and a quicker return to function. The possible downside is longer surgery time and more difficulty placing the implants in the optimal position. My The most common complication that appears later is an inflammatory reaction to tiny particles that gradually wear off the artificial joint surfaces and are absorbed by the surrounding tissues. To treat this complication, the physician may use anti-inflammatory medications or recommend revision surgery (replacement of the artificial joint). Less common complications of hip replacement surgery include infection, blood clots, and heterotopic bone formation (bone growth beyond the normal edges of bone). While this may seem like a lot to absorb, keep in mind that hip replacement surgery is the most successful surgery when comparing preoperative and postoperative function and quality of life. OE Timothy J. Panek, MD, joined St. Croix Orthopaedics in 2001. He graduated from the University of Minnesota Medical School in 1996 and completed his orthopaedic surgery residency at the University of Minnesota in 2001. Dr. Panek is board certified in orthopaedic surgery and is a member of the American Academy of Orthopaedic Surgeons. He has a special interest in arthroscopy, joint replacement, and sports medicine. He provides care to local sports teams, including the St. Paul Saints and Mahtomedi High School. Orthopaedic Excellence 5 Shoulder Repair Arthroscopic Surgery Solves a Range of Ailments By William T. Schneider, MD S houlders almost always go unnoticed, until there is pain, stiffness, or other problems. Because the shoulder has a greater range of motion than any other joint, it is more susceptible to injuries. According to the American Academy of Orthopaedic Surgeons, approximately four million people in the United States seek medical care each year for shoulder sprains, strains, dislocations, and other problems. Each year, shoulder problems account for approximately 1.5 million visits to orthopaedic surgeons. Procedures take from 30 minutes to two hours, depending on the repair’s complexity and patient considerations. Arthroscopy is performed for a range of problems — from relatively simple bone spurs to complex rotator cuff repairs. In fact, approximately 95% of the rotator cuff repairs I perform are done arthroscopically. A rotator cuff tear is a common injury for people 40 years of age and older, although younger people are also at risk. Athletes who repeatedly perform overhead arm motion, people with occupations that require extensive overhead arm motion, or people with shoulder fractures or dislocations are prone to this type of injury. Image courtesy of Arthrex During rotator cuff surgery, the surgeon first assesses the size and pattern of the tear. Usually, the tissue is torn away from the bone. Fragmented and thinned portions of the rotator cuff are removed in a process called debridement. Debridement encourages new blood vessel growth in the area where the rotator cuff will be reattached. Suture anchors are placed in the bone, and sutures pull the torn cuff tissue back to the prepared bone surface. Specialized instruments allow the surgeon to insert anchors into bone, pass sutures, and tie knots through small plastic cannulas. Arthroscopic rotator cuff surgery is often performed under a light general anesthetic, nerve-block anesthesia, or both. An additional local anesthetic, injected via catheter during surgery, continues to relieve pain in the area for 48 to 72 hours after the surgery. Postoperative Results Traditional surgeries are associated with considerable pain, prolonged recovery times, and disfiguring scars, but advancements in arthroscopy during the last few years have changed this dramatically. An Arthroscopic Approach Whether an injury or a degenerative process causes the condition, arthroscopic surgery can often eliminate pain and restore strength and function. An arthroscope is a fiber-optic device smaller than a pencil that serves as a microscope for the surgeon, sending a magnified, crystal-clear view of the structures inside the joint to a video monitor. The magnification of the arthroscope allows the surgeon to inspect the area and detect irregularities that are less than 1 mm. Operations that once required large incisions are now performed through two to four tiny incisions that range in size from 1/4 inch to the size of a shirt buttonhole. The incisions may require one stitch but often no stitches at all. Specialized instruments allow the surgeon to insert anchors into bone, pass sutures, and tie knots through small plastic cannulas. Digital electronics allow photographic and videographic documentation of the surgical findings. Arthroscopic shoulder surgery requires advanced arthroscopy skills, careful preoperative planning, and a systematic approach. 6 St. Croix Orthopaedics Most people return home the same day as surgery, even after major repairs. Shoulders tend to become stiff, so patients are encouraged to begin simple range-of-motion exercises immediately after the operation. Two to three days later, they follow up with a therapist, and many begin supervised physical therapy. Although patients feel better sooner after arthroscopic procedures than with traditional surgery, they must adhere to the postsurgical instructions to avoid disruption of the healing process. Even though the operation is less invasive, it still takes several months for a rotator cuff repair to completely heal and approximately a year before all the symptoms are resolved. The reduced pain and smaller incisions of arthroscopic surgery result in shorter recovery times and a faster return to all those responsibilities that rest on your shoulders. OE William T. Schneider, MD, earned his medical degree from the University of Minnesota Medical School. Dr. Schneider is certified by the American Board of Orthopaedics and is a Fellow of the American Academy of Orthopaedic Surgeons. He is a member of the American Academy of Orthopaedic Surgeons, the Minnesota Medical Association, and the Minnesota Orthopaedic Society. Orthopaedic Excellence 7 F or patients at Selian Lutheran Hospital in Arusha, Tanzania, a visit with St. Croix Orthopaedics’ (SCO) David Palmer, MD, was no ordinary doctor’s visit — it was a once-in-a-lifetime chance to receive treatment for debilitating, even crippling, conditions they had for years. Dr. Palmer and Physician Assistant Russ McGill spent three weeks in summer 2005 volunteering at Selian Lutheran Hospital, serving a community that had little access to orthopaedic care. Dr. Palmer and McGill worked from dawn to dusk, performing 40 surgeries a week. Many patients waited months to see them. Within days of arrival, Dr. Palmer examined more than 100 patients, 50 of whom required surgery. Call of the Wild St. Croix Orthopaedics Team Volunteers as Medical Missionaries in Africa By Nicole Achs Freeling Dr. Palmer and McGill started operating at 8:30 a.m. and finished between 6 p.m. and 8 p.m. Each day’s work included restoring crippled children to mobility, relieving adults of pain they had endured for years, and treating neglected bone injuries that had grown into dangerous, limb-threatening infections. “Even though we worked hard, it was very refreshing,” says Dr. Palmer. “We didn’t have to deal with insurance companies, attorneys, or dictating notes. It was pure medical work, which was a joy.” Under Development Located in northeastern Tanzania, Arusha is a bustling town with commanding views of Mount Kilimanjaro and a close proximity to many of the country’s prime game preserves, making it a popular stopover for Western tourists. Arusha is also home to the International Conference Center, a meeting facility where some of the most important peace treaties and international agreements pertaining to modern Africa were signed. Yet, for all its status as a modern African town, access to health care remains severely limited. The 100-bed Selian Lutheran Hospital services the 1.5 million residents of Arusha in addition to the Maasai tribespeople in the surrounding region. The African continent is a land of stark contrasts, Dr. Palmer and McGill observed, with abject poverty and unparalleled beauty existing in apposition. Many of the conditions they treated while serving at Selian Lutheran Hospital were direct results of the conditions “Even though we worked hard, it was very refreshing. We didn’t have to deal with insurance companies, attorneys, or dictating notes. It was pure medical work, which was a joy.” — David Palmer, MD 8 St. Croix Orthopaedics the people in this extremely poor community face, including contaminated drinking water, lack of access to medical care, and exposure to diseases long eradicated from the developed world. They treated bone infections that resulted from fractures that were previously neglected for days or even weeks. They corrected skeletal damage that resulted from polio. Many children were suffering from hyperflourosis, an excess of fluoride in the bones, which causes a condition similar to rickets. The drinking water around Arusha contains large amounts of fluoride. In some communities, the fluoride levels become toxic, which can cause crippling deformities in children and fractures in adults. Among the problems are knockknees, bowlegs, and microfractures. Dr. Palmer and his colleagues were able to fully correct these deformities and return normal skeletal structure to their patients. Teach a Man to Fish The SCO team continued to serve the people of Arusha even after they left by leaving behind their knowledge. When they arrived, arthroscopy, a commonly used technique in the United States that allows surgeons to conduct minimally invasive joint operations rather than full-scale open surgeries, had never been performed in that part of Africa. During arthroscopy, narrow tubes with lights and tiny video cameras attached are inserted into the joint, enabling a physician to see inside. Soliciting equipment donations from its U.S. suppliers, in particular Linvatech, Dr. Palmer and McGill took four arthroscopes, light sources, power generators, a rotary shaver to shave lesions from around joints, an arthropump to force fluid through joints, and numerous hand instruments. The SCO team trained the hospital’s general surgeon to perform the procedure and gave staff lectures during rounds. The Hospital Director, Mark Jacobsen, MD, hopes to use the suite as the basis of an arthroscopy institute in which Western physicians can further train local medical practitioners in the procedure. Selian Lutheran Hospital was set up two decades ago by Dr. Jacobsen, a longtime friend of Dr. Palmer’s. “For a developing country, it’s a nice operating suite,” says Dr. Palmer. “The hospital has an anesthesiologist and two anesthesia machines — one of which works.” The biggest adjustment to the working conditions was the pace, which was much slower than back home. Physicians also had to gather all their own equipment. “If we needed a plate and some screws for an operation, we would have to go to a back room and pick out the equipment,” says Dr. Palmer. “You have to do a lot of planning to get the right equipment for the patient.” A Lot of Good Dr. Palmer and McGill plan to return to the clinic in February 2006 to continue building relationships with patients and establish the arthroscopy practice. The two have been on volunteer missions for eight years. They have traveled to Bhutan as well as Afghanistan while the Taliban was taking over the country. During that visit, the team treated mostly civilian injuries that resulted from the fighting, such as bullet wounds and mine-related injuries. The medical providers pay their own airfares and expenses. Although it is costly to take a month off from his practice, Dr. Palmer says the work is an incredibly rewarding reminder of the difference physicians can make. In this region, people’s only ability to pay is with a heartfelt “asante sana,” which is Swahili for “thank you.” But the gratitude and warmth of the people and the rewards of dramatically improving people’s lives make the effort a joy. And according to Dr. Palmer, they are proof for him of the adage that you never give more than you receive. “These are very poor people,” he says. “One can do a lot of good.” OE Combining Experience and Expertise A Quick Look at St. Croix Orthopaedics With 17 physicians and 10 clinics throughout Minnesota and Wisconsin, St. Croix Orthopaedics (SCO) offers patients leading-edge orthopaedic care with a full range of subspecialties. As a leader in providing standard orthopaedic care for joint problems, foot and ankle surgery, sports medicine, spinal conditions, hand surgery, total joint replacement, and fracture care, the group is also one of the few in the country to offer several highly specialized services. State-of-the-art training and equipment have kept SCO physicians at the forefront of joint arthroscopy, a minimally invasive technique that allows physicians to more effectively treat problems of the knee, shoulder, ankle, hip, elbow, and wrist. SCO physicians distinguish themselves through their medical expertise, their service to the local and world communities, and their continued training in new techniques. The group includes one of the few orthopaedic foot and ankle specialists in the area, Glenn Ciegler, MD. In fact, Dr. Ciegler is one of the few surgeons in the United States performing total ankle replacements. For hand problems, SCO physicians have the ability to perform microsurgical techniques to repair nerves, arteries, and complex tendon injuries. SCO is among a select group of practices in the United States to offer endoscopic carpal tunnel release surgery. SCO has a highly distinguished sports medicine program as well. Its physicians currently serve the U.S. Ski Team, the Saint Paul Saints, and the University of WisconsinRiver Falls athletics programs. The practice offers rehabilitation programs for many injuries, including throwing- and golf-related injuries. And each year, SCO helps hundreds of elderly and severely arthritic patients regain mobility and dramatically improve their quality of life with total joint replacements. Orthopaedic Excellence 9 Replacement Technology Moves to the Spine Artificial Disc Offers Alternative to Spinal Fusion By Bruce Bartie, DO D egenerative disc disease of the lumbar spine is a common condition that affects 10 to 12 million people. In fact, 30% of adults 30 years of age and older have this condition. It occurs when spinal discs deteriorate and lose moisture, height, and the integrity of the tissue to sustain physiological loads. surgical intervention for chronic degenerative disc disease. Reduce Pain, Maintain Flexibility Some individuals, however, have an accelerated rate and intensity of this condition and become surgical patients. It is important to note that only patients between the ages of 18 and 60 are currently permitted Until the FDA approved the use of DePuy’s CHARITÉTM Artificial Disc in October 2004, fusion was the o n l y s u r g i c a l treatm e n t f o r degenerative disc disease of the lumbar spine. But total disc replacement technology has been available outside the United States since 1987, and more than 7,500 implants have been used outside the United States. Total disc replacement is an exciting new technology in that it is the first motion-preserving alternative to lumbar spinal fusion surgery. It has been shown to reduce back pain while maintaining flexibility and range of motion. This condition may cause vertebrae to rub against each other and result in significant arthritic-type pain. As discs degenerate, the usual spaces and relationships of the vertebrae change, compressing the nerves and causing additional pain, numbness, or tingling. Surgical Candidates Degenerative changes are the natural process of aging. The majority of patients who have symptoms from degenerative disc disease usually experience mild to moderate degrees of discomfort. The majority of patients who experience back pain are appropriately treated conservatively without surgery. Only 5% to 10% of patients eventually require 10 St. Croix Orthopaedics to have this procedure, according to the U.S. Food and Drug Administration’s (FDA) guidelines. Patients who suffer from osteoporosis and spinal instability (spondylolisthesis or vertebra fractures) are not candidates for this treatment. For the 10% of patients who have progressive deterioration and degenerative changes at a single level in their lumbar spines, there are now two surgical options available — fusion (a welding process of two vertebrae) or total disc replacement. Intervention with fusion or disc replacement is appropriate only after six months of structured exercise, stretching, therapy, chiropractic care, and medications have failed. Total disc replacement is an exciting new technology in that it is the first motion-preserving alternative to lumbar spinal fusion surgery. It has been shown to reduce back pain while maintaining flexibility and range of motion. Clinical Study According to a two-year clinical study, the potential complications with the CHARITÉ Artificial Disc were comparable to that of spinal fusion surgery. The results from the two-year clinical study of 375 patients done in accordance with the FDA showed that those patients implanted with the CHARITÉ Artificial Disc improved or maintained their range of motion and experienced a decrease in pain sooner than comparable spinal fusion patients. Patient pain and functional test scores were statistically superior to those of fusion patients at all points through 12 months of follow-up and were numerically superior at 24 months with higher patient satisfaction. On average, patients treated with a total disc replacement were discharged from the hospital approximately half a day sooner than fusion patients. There were no significant differences in complications between the artificial disc replacement patients and the fusion group. Radiographic follow-up showed an average range of motion of approximately 7 degrees of motion at 12 and 24 months with disc space height restored from an average of 6 mm to 13 mm at 12 months which was maintained at an average of 24 months. Procedure Techniques The CHARITÉ Artificial Disc is the first FDA-approved artificial disc to treat patients with single-level degenerative disc disease at the L4-5 or L5-S1 levels in the spine. The CHARITÉ Artificial Disc is the world’s first commercially available artificial disc. Composed of cobalt chromium endplates and an ultra-high-molecularweight polyethylene sliding core, the CHARITÉ disc system includes a comprehensive range of core heights, endplate sizes, and endplate angles. This helps ensure proper sizing, placement, and segmental lordosis. Preclinical testing indicates that the mobile-core design comprises a floating center of rotation. This facilitates independent translation and rotation, principal components of physiologic motion. the use of the CHARITÉ Artificial Disc during mandatory training programs. I was privileged to be one of the first surgeons in the Midwest to receive training on this exciting procedure. Promising New Technology The early results of the patients who have benefited from this technology have been very promising. The procedure itself has been safe and effective and has already been performed at Lakeview Hospital in Stillwater and Woodwinds Hospital in Woodbury. I am cautiously optimistic that this procedure will follow the same course that total hip and total knee replacement surgeries followed back in the 1960s for degenerative changes of the hip and the knee. OE Bruce Bartie, DO, joined St. Croix Orthopaedics in 1996. He graduated from the University of Osteopathic Medicine and Health Sciences College of Medicine and Surgery in Des Moines, Iowa. He completed a five-year residency at the Mayo Clinic and a year spinal fellowship at the Minnesota Spine Center in Minneapolis, Minnesota. Dr. Bartie is board certified in orthopaedic surgery. He is a member of the American Academy of Orthopaedic Surgeons, the American Medical Association, the American Osteopathic Association, the Minnesota Medical Association, the Minnesota Osteopathic Medical Society, the Scoliosis Research Society, and the Association of Fellows of the Mayo Graduate School of Medicine. To implant the device, surgeons create an incision in the lower abdomen and carefully expose the spine by retracting the internal organs and major blood vessels at the L4-5 or L5-S1 site. Currently, only one level can be implanted at this time. The damaged disc is removed by a specific technique. The two adjacent vertebrae are then spread apart, and the artificial disc is implanted with a press-fit technique. The procedure generally takes one to two hours. Only experienced surgeons have been trained in While the full longevity of disc replacement devices is not yet known, they are expected to follow the courses of other total joint replacement devices. Orthopaedic Excellence 11 Most bunions do not lead to serious problems, but they can cause chronic foot pain and a change in posture that can contribute to lower back, knee, and hip problems. If the Shoe Fits, Wear It Proper-Fitting Footwear Can Prevent Bunions By Troy A. Vargas, DPM H igh fashion has often put women in high heels and pointed-toe shoes. The aesthetics are debatable, but the health effects are not. The combination of slope and constriction in a stiletto-heeled pump results in compression of the big toe. And when the big toe is compressed, the bursa, or sac at the base of the big toe, becomes inflamed or swells. The result, in colloquial terms, is a bunion. In medical terms, a bunion is known as hallux valgus. Because poorly designed shoes contribute so much to the incidence of bunions, women are more vulnerable to the condition than men. But not all bunions are responses to cultural dictates in dress. Some individuals have a hereditary predisposition to bunions because of foot morphology, or form. Also, arthritis can alter joints so the toes’ range of motion changes, and they begin to rub against neighboring toes. Most bunions do not lead to serious problems, but they can cause chronic foot pain and a change in posture that can contribute to lower back, knee, and hip problems. So the pain of a bunion, like all pain, is an indicator that action is needed. 12 St. Croix Orthopaedics How Are Bunions Treated? The best treatment for bunions begins as soon as the first symptoms appear. Changing footwear and wearing wide-toed shoes is suggested. Conservative, or nonsurgical, treatment of bunions includes wide, comfortable shoes and augmentation of activity to decrease the pain. If these do not work, then surgery is indicated. There are several other conservative treatments for bunions. In addition to shoes that allow toes to wiggle, devices that act as a wedge between the big toe and the second toe can provide temporary relief. What About Surgery? For individuals who experience the formation of a bunion because of the way the toe or foot is shaped, there are a number of techniques for reorienting the toe. The best approach is matched with the specific need of the surgical candidate. The surgery is not as simple as cutting off a bump. It involves cutting the bone and shifting it. Since bunions are caused by misalignment of bone, the surgery is a major reconstruction of the forefoot. Following bunion surgery, the foot needs protection for at least four weeks, and full recovery takes several months. Initially after surgery, the patient is also often required to keep weight off the foot or walk in a specially designed shoe. Bunion surgery is not a cosmetic procedure; it is for alleviating pain. After surgery, patients must exhibit commitment, as full healing requires a lot of work on their parts. OE Troy A. Vargas, DPM, is board certified by the American Board of Podiatric Surgery and is a Fellow of the American College of Foot and Ankle Surgeons. He specializes in reconstructive foot and ankle surgery. Dr. Vargas was recognized as a “Top Doctor” in the Minneapolis/St. Paul magazine top-doctor survey for his field of medicine. He received his medical degree from the College of Podiatric Medicine and Surgery at the University of Osteopathic Medicine and Health Sciences in Des Moines and completed his surgical residency at Hennepin County Medical Center in Minneapolis. Dr. Vargas joined St. Croix Orthopaedics in 2000. Orthopaedic Excellence 13 Get a Grip Relief from Carpal Tunnel Syndrome By Ryan R. Karlstad, MD C arpal tunnel syndrome (CTS) is the most common problem treated in the hand and wrist. Consequently, surgery for CTS is the most common hand operation performed in the United States today. Women are three to four times more likely to present with CTS than men. It may begin at any age but is most frequently seen in the 25- to 50-year-old age bracket. Signs and Symptoms The carpal tunnel is a narrow, rigid pathway formed by the transverse carpal ligament in the wrist. The median nerve and nine flexor tendons pass through this pathway. CTS develops when the median nerve becomes compressed within this tunnel, impairing its ability to transmit nerve impulses from the thumb, index, middle, and ring fingers and leading to pain, numbness, and weakness in the hand and forearm. Although CTS is frequently diagnosed based on history alone, a physical examination can detect a decrease in the size of the muscles in seem to have a limited role in treating CTS. Local steroid injections may have a more rapid and profound effect on reducing swelling and relieving pain. Surgical Options If conservative care fails, CTS surgery is typically performed as an outpatient procedure with local anesthesia. A surgeon protects the median nerve while the transverse ligament is cut. The ligament eventually reconstitutes itself in a lengthened position. The nerve is given more room, and symptoms are usually immediately improved. CTS surgery is performed in either an open or endoscopic fashion. Both offer potential risks and benefits. An open carpal tunnel release is performed by making an incision longitudinally over the carpal tunnel at the base of the palm, which renders it susceptible to pain when gripping or applying pressure to the palm. The transverse carpal ligament is directly visualized and is transected above the Studies have shown that the percentage of patients who return to work after three weeks is higher following the endoscopic procedure than it is after the open procedure. the hand served by the median nerve. Diminished sensation or sweating is often evident in the thumb, index, and middle fingers. Symptoms may worsen when the wrist is held in a flexed or extended position. A Conservative Approach As long as symptoms are mild, are infrequent, are transient, and completely resolve, no specific treatment is necessary. Identifying and limiting those activities that cause symptoms is often the best advice. Splints worn when sleeping prevent the flexion posture of the wrist that tends to aggravate nighttime symptoms. Anti-inflammatory medications 14 St. Croix Orthopaedics ligament. The open surgery’s incision is slightly larger than that with an endoscopic carpal tunnel release. Endoscopic carpal tunnel release is performed by making the transverse incision in line with the skin creases at the wrist. A camera is then inserted beneath the transverse carpal ligament, and a knife at the end of the camera is extended. While watching on a monitor, the surgeon cuts the transverse carpal ligament. Risks and Results The risks of an endoscopic carpal tunnel release include a potentially increased risk of an incomplete release of the transverse carpal ligament relative to an open carpal tunnel release. Generally, postoperative discomfort is decreased by this less invasive procedure. Studies have shown that the percentage of patients who return to work after three weeks is higher following the endoscopic procedure than it is after the open procedure. Cross-section of the right hand at the level of the wrist to show the anatomy involved in carpal tunnel syndrome Although there are differences in approach, both surgeries provide more room for the median nerve. After three months, patients have the same frequency of complications, pain, and restoration of nerve function regardless of the approach. OE Ryan R. Karlstad, MD, attended Harvard University and graduated from The Johns Hopkins School of Medicine. After completing his orthopaedic surgery residency at the Mayo Clinic in Rochester, Minnesota, Dr. Karlstad received fellowship training in hand surgery at the UCLA Medical Center in Los Angeles, California. He is board certified in orthopaedic surgery and is a member of the American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand. He is also a member of the American Medical Association. Directory St. Croix Orthopaedics thanks the following advertisers for their support. 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