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.
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Robert Nuffort, CEO
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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.
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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.
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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
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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
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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
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1991 Northwestern Avenue South
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