April 2, 2020

Outstanding Achievements

Jeffrey R. Carlson, MD, Orthopaedic & Spine Center: Cervical Disc Arthroplasty

 

The next generation of artificial cervical discs is all about motion. As alternatives to spinal fusion surgery – which permanently immobilizes damaged regions of the neck – the newest replacement prosthetics aim to mimic the body’s natural structure and movement. 

Dr. Jeffrey Carlson, a fellowship-trained orthopaedic spine surgeon, has closely followed the development of one such promising device: the M6-C artificial cervical disc, built with a viscoelastic nucleus, fiber annulus and titanium endplates to absorb shock and promote full range of motion.  

The artificial disc received FDA approval in February 2019. This fall, Dr. Carlson became the first surgeon in Virginia to complete the training required to offer it to patients.

“I believe spinal surgery will increasingly go in this direction in the future,” he says. “Especially for younger patients, this is a better option for lifelong benefits and long-term function in the neck. Bodies simply do better in motion.” 

For patients with cervical disc degeneration, disc replacements aim to ease pain yet minimize harmful stress on adjacent vertebral segments, a common complication after anterior cervical discectomy and fusion. 

Fusing vertebrae with a bone graft and plate is often effective for pain relief, but the procedure leads to limitations on activity. Advanced artificial discs, on the other hand, support motion in all directions: backward and forward, side to side, up and down, and left and right. 

Instead of spending extended periods resting or wearing a brace, patients are encouraged to move around shortly after surgery. That push to return to action sooner follows similar trends in total knee and hip replacements.  

Dr. Carlson has successfully performed disc replacements in the neck for more than 15 years, starting with now outdated metal-on-metal prosthetics. He believes improved designs and materials will transform treatment for patients who have a herniated disc or arthritis but still have healthy and mobile bone segments surrounding those areas. 

“If it’s just a disc that’s the problem and not the bones themselves, why fuse them?” he asks. “Why not fix that one problem and put something in there that moves? My feeling is that applications of this will one day turn cervical spinal fusion into a secondary option.” Replacements also can be an option for patients with spinal stenosis, he adds. 

Based on positive outcomes in his patients and a growing number of national studies, Dr. Carlson has been a strong advocate for insurance coverage of cervical disc replacement procedures. Like most fusions, the surgeries typically can be done on an outpatient basis. 

Studies on the M6-C device, for example, showed 91.2 percent of patients reported an improvement in neck pain versus 77.9 percent of anterior cervical discectomy and fusion patients; rates for improvement in arm pain were 90.5 and 79.9 percent, respectively. Patients also had a reduced rate of opioid use for post-surgical pain relief. 

The next step could be research into the efficacy and benefits of two-level disc replacements – potentially another step away from fusions. 

“Our mission is always to look for the best options to get patients back to the life they love, with as much natural function as possible,” Dr. Carlson notes. “My goals in spine surgery innovation have always been to advance technology and equipment that helps us do that.”

Outstanding Achievements is a new feature that recognizes a local physician for accomplishments in the areas of education, medical innovations or introduction of new treatments and technologies to the region. It is our honor to recognize these accomplishments.

 

Please let us know if there is a physician who deserves recognition in this column. Email: holly@hrphysician.com

Gloucester Mathews Care Clinic

Wayne J. Reynolds, DO,
Sentara Family Physicians Gloucester

 

For more than two decades, the Gloucester Mathews Care Clinic has helped hundreds of people a year manage medical problems that they otherwise couldn’t afford to treat.  

The Care Clinic and its on-site pharmacy have kept countless uninsured patients, most of them working poor, out of emergency rooms and urgent care centers. A group of dedicated primary care providers, specialists and support staff offer acute and chronic care, mental health services, prescription medications, referrals and patient education.  

“As a rural area, we have a lot of small employers who are very productive in the community but simply can’t afford to provide health coverage,” notes Dr. Wayne J. Reynolds, a family physician and the clinic’s Medical Director. “There’s a sizable group of people who fall through cracks in the system, who likely would only seek care once they had a major problem.”  

The Clinic is open to uninsured adults in Gloucester and Mathews counties who meet income criteria and are employed or actively seeking a job. It has grown dramatically since its 1998 founding by a group of concerned parishioners from Abingdon Episcopal Church.  

In its first year, the program served 100 patients out of a 1,100-square-foot building; by 2014, it had relocated to a 9,000-square-foot space on Industrial Drive in Gloucester. In 2018, staff saw 903 patients through 4,755 medical and dental visits, while filling 22,472 prescriptions.  

Nearly 30 medical professionals volunteer alongside a paid part-time doctor and nurse practitioner. Altogether, they donated 13,076 hours of work in 2018 and, with pharmaceuticals factored in, $11 million-plus in healthcare services. Dr. Reynolds, who has practiced in Gloucester since 1995, has served as Medical Director since 2003.  

Specialty care includes endocrinology, gastroenterology, orthopedics, podiatry, psychiatry and rheumatology. Chronic illnesses that need continuous attention, such as diabetes, heart disease, high blood pressure and hyperlipidemia, are common.  

Along with regular monitoring and medications, medical staff emphasize patient education, as well as gently correcting harmful misconceptions. For example, people often think high blood pressure causes obvious symptoms, or that exercise habits aren’t connected to diabetes control. Medication compliance is another problem.  

“As people start to feel better, they think they can skip the medication,” Dr. Reynolds explains. “Or, even worse, they think they can share with someone else in their same predicament – lacking insurance – to try to help them out.”  

While originally founded as a church outreach project, the Gloucester Mathews Care Clinic is non-denominational and currently funded through grants and individual contributions. Appointments are available most weekdays, with some evening options for urgent situations. Staff also can arrange transportation in certain circumstances.  

To reach even more individuals in need, the clinic recently raised its patient eligibility threshold to 300 percent of the 2019 Federal Poverty Level, or $37,470 for an individual and $77,250 for a family of four. It also has implemented an Electronic Medical Record system and streamlined screening and referral processes to reduce waiting times for appointments.  

The biggest ongoing change, though, is a transition to accept Medicaid-enrolled patients, following Virginia’s decision to expand those benefits.  

“We want to be able to continue to serve some of those patients who newly qualify for Medicaid, but who want to stay with our clinic because of the relationships they’ve formed,” Dr. Reynolds relates. “We’re proud of those deep connections.”  

The effort is all part of a drive to increase awareness that quality community-based care is accessible for people struggling with healthcare costs.  

“We’ve been in our community for 21 years, but unfortunately we’re still somewhat of a best-kept secret,” Reynolds says. “We really encourage more potential patients to reach out to us.”

 

For more information or to schedule an eligibility appointment, visit gmcareclinic.com or call (804) 210-1368.   

The Arthritis Foundation, Hampton Roads Chapter

Nicolai B. Baecher, MD,
Sports Medicine & Orthopaedic Center, Inc. (SMOC)

 

Arthritis is astonishingly common: one in every four Americans will suffer from a form of joint inflammation, pain and stiffness, sometimes beginning in early childhood. In the military community, that percentage rises to one in three people. 

The Arthritis Foundation’s local chapter is a vital advocacy and educational group for Hampton Roads families. Its work includes connecting patients to information and community resources, organizing fundraising events, lobbying for legislation to benefit patients, hosting support groups, and sending children with arthritis to special summer camps. 

“The Foundation is critical to research funding, which has aided in the treatment options that I am able to offer to my patients,” says Dr. Nicolai Baecher, an Orthopaedic Hand & Upper Extremity Surgeon with SMOC. “Supporting it is one way I can ensure research and more opportunities for treatment continue – and that one day a cure will arise.”  

As a regular supporter of the nonprofit, Dr. Baecher was this year’s Orthopaedic Medical Honoree for its annual Jingle Bell Run; SMOC was the event’s presenting sponsor and entered its “Jingle Joggers” team. “I am very proud to help raise money for such a good cause,” he says.

In its many varieties, arthritis effects more than 52 million Americans and is the leading cause of disability for adults. In Virginia alone, 1.6 million people struggle with the chronic disease, including 7,200 kids. 

While there is still no cure, new treatments and surgical techniques can make a dramatic difference in patients’ lives. The Arthritis Foundation has invested half a billion dollars in research to date, leading to the first biologics for a number of disease types.  

“Arthritis is everywhere, and it impacts entire families,” notes Kimberly Twine, Development Manager for the Arthritis Foundation’s Virginia Beach office. “Our mission is bold. We fight to cure arthritis, and our local programs provide personalized help for patients.”  

One current effort is tailor-made for the Hampton Roads community. The Foundation is leading a national push for additional Department of Defense funding to investigate a higher incidence of arthritis in active duty service members and veterans. For example, osteoarthritis rates are 26 percent higher in the under-20 age group as compared to the general population. 

Factors such as carrying heavy equipment, undergoing rigorous training and experiencing combat injuries – including shock waves from bomb blasts – may contribute to early joint damage. Furthermore, post-traumatic osteoarthritis can be severely debilitating. 

After years of focusing more on rheumatoid arthritis, the Foundation also has pivoted to concentrate on osteoarthritis, which accounts for more than 25 percent of all arthritis-related health care visits. “We are hoping and expecting to see major developments in new therapies for osteoarthritis, as has happened with rheumatoid arthritis,” Twine says. 

To raise money for its work, the local chapter hosts the Jingle Bell Run each November, also an opportunity to educate families on preventive measures such as regular exercise, a healthy diet with anti-inflammatory foods, necessary weight loss and proper footwear. 

Other annual events include several walks, family days with kids’ activities, and the popular Beef, Bourbon and Blues festival in February with dinner, dessert, drinks, live music and an auction. Juvenile Arthritis summer camps held in Charlottesville allow kids and teens to connect, learn to manage their disease and try fun new activities.   

Additionally, the Hampton Roads office recently launched a patient support group in Chesapeake, the first step toward its goal of running groups in each of the region’s seven cities.  

“Arthritis places a huge physical, emotional and financial burden on families,” Twine says. “We are happy to be here to help lift some of those away.”

For more information, visit arthritis.org/virginia. 

Joe Roenker, PA-C

Bayview Cardiovascular Associates

 

Not many providers get to help save lives at the hospital where they were born. Joe Roenker, a Physician Assistant specializing in cardiology, has that rare privilege at Sentara Virginia Beach General Hospital. 

Roenker has spent the past five years at Bayview Cardiovascular Associates, a large regional practice and primary provider of cardiac care at the hospital. There and in the outpatient setting, the Virginia Beach native aims to build collaborative partnerships with patients by taking the time to carefully explain each test and treatment. 

“It’s important to me that they understand their disease and its particular stage,” he says. “If they feel as if I’m working with them – not just doing things to them – they’re more likely to embrace needed medicines and lifestyle and mindset changes to enjoy the best quality of life.”

Most of Roenker’s patients are older than 65 and often grappling with a variety of complex health concerns beyond cardiovascular disease, such as chronic pulmonary conditions, kidney diseases or injuries, and gastrointestinal or liver complications. 

“It’s challenging work, but I love it,” he relates. “Not only do I get to focus on what I consider the most important organ in the body, but with almost every decision that I make about the heart, I have to consider how it might impact the rest of the body.” 

Thankfully, treatments for many forms of heart disease have advanced significantly in recent years. For example, patients with congestive heart failure now have access to both effective new medications and devices that can reduce the risk of hospitalization. 

One such device is the CardioMEMS, a dime-size implant that measures changes in pulmonary artery pressure, a frequent early warning sign of decline. A miniature wireless sensor, inserted into the artery via a catheter procedure, transmits blood pressure and heart rate data and can alert physicians to intervene.   

“More and more, we have the knowledge and tools to make a difference in patients’ lives on multiple levels,” Roenker notes. “It’s so rewarding when patients tell me that they’re glad they had an appointment with me because they leave feeling stronger or more optimistic.” 

Medicine has been a perfect fit for Roenker, who graduated from Princess Anne High School and attended the College of William & Mary on a baseball scholarship. As his childhood dream of pitching for the Atlanta Braves faded during an injury-filled senior season, he turned his focus to his longtime interest in science.  

Kinesiology degree in hand, Roenker briefly considered a career in physical therapy but opted to take a job as a technician in Sentara Virginia Beach General’s cardiac catheterization lab, where his mother is Nurse Manager and he would spend four years. 

After discovering a talent for staying calm in emergency situations, Roenker soon grew fascinated with the function and pathology of the heart. He also connected with local cardiologists, some now co-workers, who suggested the PA path.  

Roenker completed a Master of Physician Assistant degree at Eastern Virginia Medical School and has been with Bayview ever since. A member of the American Academy of Physician Assistants, he is based primarily at the group’s Virginia Beach office when he’s not at the hospital. Caregiving runs in his family: in addition to his mom, his sister is a fourth-floor nurse at Virginia Beach General, and his brother is a firefighter in Portsmouth. 

Outside work, Roenker enjoys golfing, playing guitar and participating in church activities. With deep roots in his hometown, he is happy to have found such a fulfilling career right out of training.  

“At the end of PA school, we were told, ‘Fifty percent of you will switch specialties after only a year,’” he recalls. “Most PAs do change at least once during their careers, but I really don’t see myself ever doing anything else. To me, cardiology is endlessly interesting.” 

 

We are grateful for local Nurse Practitioners and Physician Assistants who serve our health care community! Please let us know if there is an NP or PA you would like to see honored in a future edition. holly@hrphysician.com

Obesity and Weight Loss: How It Affects Our Joints

By Scott Grabill, DO

 

Obesity is a well-known risk factor for developing bone and joint problems. It has a cumulative effect on patients’ joints over their lifetime. Excess body weight leads to increased forces across the joints, as high as four to seven times the body weight in the knees and hips. Obesity can lead to a lifetime of wear and tear that would not occur in a patient at optimal body weight. 

Even older patients who only become obese later in life can feel the effects in their joints. If they suffer from arthritis or other musculoskeletal conditions, their symptoms become more problematic and existing pains become worse, especially in weight-bearing joints. Symptoms may not bother some patients very much at first, but with sustained weight gain, forces involved in the mechanics of walking, sitting and standing are altered, often leading to development of pain. Weight gain can cause more pain than a patient might have had with the same condition but at a normal weight. 

Obesity also is a significant risk factor for surgical complications. Overweight patients who may be a candidate for surgery, specifically knee or hip replacements, are at a higher risk for infections, mechanical failure of their joint replacement, and blood clots such as DVT and pulmonary embolism.  This is true for both patients who become overweight later in life and those who have struggled with extra pounds throughout their lifetimes. 

While there are multiple factors involved in the development of bone and joint diseases – including genetics, previous injuries, and cumulative wear and tear – obesity can play a major role. 

One of the most common ailments for patients who are obese for an extended period of time is osteoarthritis, which results in pain, swelling and loss of motion in joints due to a breakdown of cartilage. 

Other issues include nutritional abnormalities, metabolic syndromes like diabetes, and osteoporosis. These conditions lead to decreased bone density, placing patients at risk for fractures. In addition, obese patients experience higher forces that may contribute to additional damage such as joint dislocations, torn meniscuses, and sprained ligaments, which can be more severe with increased body weight. 

The good news is that weight loss can reverse many of the problems associated with obesity. When patients lose weight, they can feel better. As weight decreases, joint problems become less symptomatic and less painful. Weight loss can even slow the progression of diseases. From a surgical standpoint, if patients lose their extra pounds before surgery, they can return to a normal risk profile. 

With weight loss and proper care for their joint disease, most patients can return to a healthy lifestyle of activities they enjoy!

Dr. Grabill is a Board certified orthopaedic surgeon at Sports Medicine and Orthopaedic Center, based in Chesapeake. He specializes in knee and hip joint replacement and treatment of arthritis. www.smoc-pt.com

Lower-Cost Procedure Alternatives in an Ambulatory Surgery Center

By Michael Fabrizio, MD, FACS

 

The national push toward value-based care is transforming many aspects of healthcare delivery, including where specialty procedures are performed. 

Just a few decades ago, virtually all surgeries occurred in hospitals. Yet increasingly, minimally-invasive surgeries are moving out of hospital outpatient programs entirely and into ambulatory surgery centers (ASC), reducing costs by anywhere from 25 to 50 percent.  

In Urology, we have found certain procedures are ideal for an ASC setting and same-day service, including: Endoscopic procedures such as cystoscopy and ureteroscopy, to treat issues such as kidney and bladder stones, bladder and prostate procedures, ESWL (a procedure to break up kidney stones), and even more complex urological procedures. 

Patients should feel confident that a lower-cost procedure in a surgery center will be equally effective and safe – if not safer – than one performed in a hospital. Improvements in operative techniques, anesthesia delivery, pain medications and medical equipment, including advanced robotic tools, have paved the way for faster, less invasive treatments.

For medical practices, ASCs involve lower overhead costs, fewer staffing inefficiencies, greater ease of scheduling, close partnerships between physicians and a dedicated staff and, generally, better control over cleanliness and infection prevention. 

Unfortunately, large hospitals systems often try to leverage their “in-house” insurance plan and forbid participation in these lower cost ASCs, directing patients to higher-cost hospital environments which in turn raises premiums and deductibles for patients and the companies insuring them.

Hospitals also state that if surgeons are allowed to operate ASCs in Virginia, they will only work with insured patients. Nothing could be further from the truth and in fact, most surgical practices provide a significant volume of unreimbursed care for the uninsured or under-insured. In fact, on a percentage basis of revenue, our practice for example provides as much or more unreimbursed care annually as any hospital system.  

While health systems can actually get reimbursed for their unreimbursed care through Section 1887 of the Social Security Act, physicians cannot apply for such reimbursement and are not even allowed to “write off” for tax purposes any of their unreimbursed care. Physicians who own or participate in ambulatory procedures centers will still provide such care, and in fact promise to do so in the COPN application.

Looking ahead, patients and healthcare companies should be prepared for ASC services to continue to grow and disrupt traditional care models. Along with consumer preference and closer cost scrutinization by patients and government entities, new technology is constantly redefining what is possible in outpatient services. 

According to the consulting firm Future Market Insights, LLC, the ASC market is projected to experience a 4 percent compound annual growth rate from 2017 to 2027, as outpatient volumes steadily rise and inpatient numbers fall.

Specialty surgery practices should strive to deliver high-quality, low-cost, consumer-driven care, featuring the most effective and minimally-invasive therapies possible. In my view, the ability to offer such procedures in an advanced ASC will be ever more critical to that mission.

Michael Fabrizio, MD, FACS, is a Professor of Urology at Eastern Virginia Medical School, President of Urology of Virginia, and on the Board of the Large Urology Group Practice Association. urologyofva.net 

Targeted Therapy: Striking Cancer Cells from Within

By Jared Kobulnicky, MD

 

One of the most promising developments in cancer treatment over the past few years is the rapid emergence of targeted therapy.  

Unlike chemotherapy and immunotherapy, targeted therapy attacks specific mutations in the DNA of cancer cells. The goal is to interfere with growth processes inside those cells – the signals that drive a disease – with fewer side effects than traditional chemotherapy.  

The first versions of targeted therapy appeared in the 1990s and treated chronic myeloid leukemia. Since then, research has led to a growing understanding of different cancer subtypes at the molecular level, allowing for the development of more precise treatment options.  

There are now dozens of approved targeted therapy medications, with many more promising drugs in clinical trials or in the early stages of development. Physicians have seen particularly positive results in the treatment of advanced melanoma and lung cancer, and we are expanding uses to other more commonly seen diseases such as breast, colon and prostate cancer. 

Each medication targets precise structural alterations in the DNA of cancerous cells or tissues that fuel a tumor’s growth, such as surrounding blood vessels, without harming any healthy cells. Therefore, these medications impact only malignant cells by blocking gene signals that instruct them to divide rapidly or stay alive longer than normal cells. 

While side effects vary by patient and disease type, they tend to be less disruptive and more predictable than those experienced with chemotherapy. 

Next-Generation DNA Sequencing is the best way to pinpoint candidates eligible for targeted therapy. Testing from blood or tumor samples reliably maps chemical building blocks and mutations within cancerous cells to determine if there is an approved medication for that particular anomaly. 

For example, about half of advanced melanomas have a mutation in the BRAF gene, which alters a protein involved in cell growth and leads to uncontrolled division. Inhibitors that interfere with an enzyme responsible for protein activation have proven highly effective in hindering cell division.  

Targeted therapies typically involve taking pills at-home at least once daily, a much more convenient option for patients than in-office infusions. For now, these drugs tend to be employed as standalone treatments to avoid potentially harmful side effects. However, ongoing research may discover we can combine them with other treatments for even better results. 

Currently, physicians are prescribing targeted therapy for patients with advanced diseases that have metastasized or recurred after previous treatments. However, oncologists are increasingly using the medications for treating earlier-stage diseases.

At VOA, we have seen positive results in patients with melanoma, lung cancer, breast cancer, leukemias and lymphomas, as well as other tumor types.

Patients should understand that chemotherapy, radiation and immunotherapy can all be highly effective treatment options, depending on cancer type and stage, and will continue to play crucial roles in disease management. 

Still, the future looks bright for targeted therapy, as individualized cancer care steadily progresses into more of a treatment norm than an exception. This should inspire great optimism in patients and physicians alike.  

Dr. Kobulnicky is a medical oncologist and hematologist with Virginia Oncology Associates, based primarily in Hampton and Newport News. Virginiacancer.com

Improving Patient Outcomes for Dupuytren’s Contracture

By Nicholas A. Smerlis, MD, FAAOS, CASQH

 

Around 15 million Americans ages 35 and older are diagnosed with Dupuytren’s contracture, the most common heritable disease affecting connective tissues. Primarily known as a progressive hand deformity, Dupuytren’s contracture is associated with diabetes, hyperlipidemia, alcoholism, and a variety of other medical conditions. Progressive Dupuytren’s contracture can interfere with hand function, making it challenging to perform everyday tasks.  

With no known cause, Dupuytren’s contracture can be a puzzling and often frustrating condition to treat. Reoccurrence is common, and complications can result depending on the state of deformity. As the disease progression is slow and unpredictable, identifying signs and symptoms early on can improve patient outcomes and reduce the need for extensive surgical intervention. In patients younger than 50, progression is sometimes faster. Smoking and high alcohol intake increase the risk of the disease. Evidence also suggests a higher prevalence among patients of Northern European descent, which is where the nickname “Viking’s disease” originated. 

Typically developing over a period of years, the earliest manifestation of Dupuytren’s contracture is a painless nodule on the palm. This disease can be distinguished from other hand contractures because it starts as a nodule and progresses to a contracture of the fingers. 

The degree of contracture affects hand function and influences treatment. In mild cases, the hand still functions well and observation is appropriate. In fact, the initial nodule does not need surgery and does not imply that the disease will progress. When hand function is compromised, however, the finger(s) may need to be straightened.

Two types of approaches to Dupuytren’s contracture may be considered depending on the stage and pattern of the disease. A fasciotomy cuts the cord like a rope, while a fasciectomy removes the cord and associated nodules from the palm and/or fingers. The goal of both is to straighten the finger to improve hand function.  

A fasciotomy can be performed by different techniques: open, needle, or chemical. In the open technique, an incision is placed on the palm in the operating room to expose the cord while protecting the surrounding structures. Both needle and chemical fasciotomies are done in the office. A needle release requires sweeping the tip of the needle back and forth across the cord to divide the abnormal fascia, whereas a chemical fasciotomy relies on dissolving an area of the cord to straighten the finger.

Conversely, a fasciectomy involves an incision in the operating room spanning the length of the cord, and it sometimes requires skin grafts to close wounds. This technique improves the ability to straighten the fingers and shows a lower risk of recurrence at the expense of greater recovery and complications.

Nicholas A. Smerlis, MD, FAAOS, CAQSH is a fellowship trained, Board certified orthopedic hand surgeon specializing in the surgical and non-surgical treatment of the hand, wrist, and elbow. He practices at TPMG Orthopedics in Newport News and Williamsburg. mytpmg.com

How NOT to Sink Your Own Battleship From the Perspective of a Malpractice Defense Attorney and Surgeon’s Daughter

By Robyn Ayres

 

I mentioned to my father that I was going to write another article, and he suggested that I be practical and “just tell us how not to be our own worst enemy”.  On that note, here are a few pointers.

Everyone knows how important documentation is, but in this age of electronic medical records, it is even more important. For the most part, EMRs have not made charting better. They rely on templates and dropdown menus and less so on narrative notes, which are often the most critical part of the chart. Take the time to do a thorough narrative note, even if you’re exasperated by all of the clicking and scrolling. If you provide pamphlets or draw diagrams for your patient, document those and keep a copy.  

Whenever possible, have someone else with you whenever you see a patient, even if it is not a sensitive type of exam. In the unfortunate event that your patient becomes incapacitated (or dies) and cannot give her version of the discussion, the details of what was said will generally be inadmissible in court unless there is some corroboration of your version of events – either specifics contained in a chart or testimony from the other person who was in the room. For instance, say a patient is seen post-operatively by her surgeon. She looks well, reports feeling well and having walked to the bathroom, and wants to go home. The surgeon does not document this interaction, and the patient dies of sepsis days later. With no corroboration of that conversation, a jury would likely never know about it.  

If you are sued for malpractice and have to give a deposition, make time – at least two hours – to meet with your attorney and prepare. The deposition is sworn testimony which will follow you into the courtroom for trial. In fact, most defendant physician depositions these days are videotaped, and patient’s lawyers like to play portions of those taped depositions at trial. You do not want to be sitting at trial six months or more after giving a deposition and watch yourself give poorly thought-out responses. I suggest doing a mock deposition with your attorney acting as the patient’s attorney. Some patient’s attorneys treat depositions of defendant physicians like a board exam and will ask a host of detailed questions about anatomy, drug interactions, medical literature, etc. Take the time to re-familiarize yourself with the issues in your case if you are a little rusty. For instance, in the heat of the stress of a deposition, you don’t want to misstate the name of a nerve branch or how far the ureter is from some other landmark. If you are asked to give a deposition in a malpractice suit in which you are not named, for example as a treating provider, generally speaking you should still have legal representation.

Robyn Ayres joined Goodman Allen Donnelly in 2004 and has devoted her practice to defending physicians, nurses, hospitals and other health care providers in malpractice litigation. She also represents nurses and physicians in licensing and discipline matters before professional boards, and advises health care providers on quality assurance issues, patient safety and risk management. 

www.goodmanallen.com

The Emergence of Stemless Shoulder Replacements

By John W. Aldridge, MD, F.A.A.O.S.

 

Stemless joint replacements, a promising innovation that utilizes press fit/bone technology first developed in hip surgery, are beginning to transform total shoulder arthroplasties.  

This option conserves more of the patient’s natural bone by replacing only the damaged ball of the shoulder and a small segment of the humeral head. That compares to coring out the humerus bone to insert a metal stem, after dissecting the deltopectoral interval for access.  

In stemless procedures, a cone-like structure is press-fit into the top of the humerus, without using cement. The prothesis instead contains a three-dimensional porous coating that promotes bony ingrowth. 

The anticipated advantages are clear, particularly for younger, more active and more muscular patients, or for most anyone with good bone health. The surgery tends to involve smaller incisions and implants and less muscle dissection, as well as no violation of the humeral canal. 

In my experience over the past six months, patients experience less post-operative pain and bleeding as compared to the traditional approach. Anecdotally, they also have recovered their natural shoulder function and mobility more quickly. 

The stemless option, generally done on an outpatient basis, reduces the risk of an intra or postoperative fracture and removes the threat of stem-related complications. Additionally, patients are left with more natural bone should they require a revision in the future.  

This fast-growing alternative, part of a movement toward minimally invasive surgeries and already prominent in Europe, now represents about 30 to 40 percent of total shoulder arthroplasty cases in my practice. 

This figure should steadily increase as orthopaedists treat more younger patients, along with older adults who have remained active and retained good bone density. Stemless prostheses also can be beneficial in posttraumatic reconstruction cases, in which bone deformities can complicate or even preclude use of a humeral stem. 

To sound a note of caution, not all patients are candidates for a stemless joint replacement. In particular, those who have osteoporosis, osteonecrosis or another bone disorder often don’t have the skeletal structure required to support a press-fit design.  

Still, the development has followed a similar path to smaller femoral replacements in total hip arthroplasty, which reduce the diaphyseal disruption of the femur. As in hip cases, shoulder stems first grew progressively shorter, especially during the past five years, until the press-fit stemless option gained more widespread acceptance.  

While long-term data is not yet available, stemless shoulder prostheses theoretically would be less prone to loosen, as the body’s own bone should grow into them for stable anchoring. Traditional shoulder prosthetics typically last 10 to 20 years, and there have been some issues with stability and longevity using shortened metal stems.

Early studies on stemless implants have demonstrated comparable outcomes to the latest standard procedures after about a decade, with a significant improvement in patient satisfaction. I expect more such positive data to accumulate in future years. 

I am happy that this effective alternative for many shoulder patients has arrived in Hampton Roads, and I am looking forward to helping people return as quickly as possible to their normal daily lives and the activities they love.

Dr. Aldridge is a Board certified orthopaedic surgeon who specializes in minimally invasive total joint replacement and muscle-sparing spinal surgery. hrosm.com