Orthopedics

Orthopedic surgeons, physiatrists, and their patients writing on KevinMD about musculoskeletal care: back pain and the procedures that can weaken a young spine, knee and joint surgery, spinal stenosis treated least invasive first, non-opioid pain management and how it is paid, orthopedic residency and the women entering it, and what a patient in pain needs to be asked. Two maintained records draw on this archive: Opioids: what physicians and pain patients say, in their own words and Surgeons and surgery: what surgeons say, in their own words.

The high cost of health care: Blame the financial model

Robert Pearl, MD

Health Policy

January 28, 2014

The primary debate in health care reform this past year centered on insurance coverage. The next great debate will focus on the cost of providing health care.

For decades, the way we’ve paid doctors and hospitals has driven up health care costs. And while the pace of health care spending has slowed the last four years, it continues to rise faster and more noticeably than improvements in U.S. health care outcomes.

The reason is not …

Does your joint replacement have a warranty?

Brian Hatten, MD

Physician

January 26, 2014

Should joint replacement manufactures provide a warranty for their products? It seems pretty logical since most consumer products come with some sort of warranty these days. Basic warranties are almost universally provided and the market for extended warranties is increasingly popular.

Take for instance my recent upgrade to the new iPhone 5s. At the time of purchase, the AT&T store suggested their extended …

MKSAP: 76-year-old woman with left knee pain

mksap

Conditions and Diseases

January 4, 2014

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. …

Is arthroscopic surgery for a partial meniscal tear unnecessary?

Jennifer Gunter, MD

Conditions and Diseases

January 2, 2014

Arthroscopic knee surgery is big business in the United States. Arthroscopic partial meniscectomies alone cost $4 billion per year. Yes, billion. But do they work?

I’ve written previously about arthroscopic surgery for a torn meniscus and how it adds nothing above and beyond physical therapy for people with arthritis. We also know that arthroscopic knee surgery for arthritis isn’t effective either. Given the poor performance of these other arthroscopic surgeries, answering the …

The consequences of zero tolerance: Why HIPAA is overkill

Michael Kirsch, MD

Physician

January 1, 2014

Everyone is familiar with the acronym HIPAA, which is the 1996 edict called the Health Insurance Portability and Accountability Act. Isn’t that a smooth and melodious name?

These are and regulations that are designed to protect your confidential protected medical information. I support the mission. I don’t think that your medical records should be deliberately or inadvertently shared with those who are not lawfully permitted to view them.

Medical charts (remember when …
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The consequences of zero tolerance: Why HIPAA is overkill

The job of the modern doctor is to convince

Tiredoc, MD

Physician

December 29, 2013

The job of a doctor isn’t to diagnose, prescribe, or examine. It isn’t to be well read, efficient, or punctual. The job of the modern doctor is to convince.

We now have radiological studies whose theoretical discernment limit is subcellular. We can not only map clear and obvious genetic errors of metabolism, but also minor variations of the normal. In a few years, the majority of codes in the procedure manual will probably be laboratory …

Tips for treating patients suffering from chronic pain

David Hanscom, MD

Physician

November 22, 2013

“You are the worst doctor I have ever met.”

This was the second patient in a row to explode at me when I explained that further back surgery for his back pain had a low chance of success. I spent a couple of minutes explaining the many successes of our hospital’s pain program. Then he exploded again: “You mean I drove five hours just to hear you tell me that you …

You have no idea how important your arm is until you can’t use it

Skeptical Scalpel, MD

Physician

October 30, 2013

Recently, I underwent surgery for what proved to be an extensive tear of my right rotator cuff.

I have never had a major operation before. Here is how it went down.

Back in July, I felt a sharp pain in my right shoulder while playing tennis. Of course, I continued to play that day and for two more weeks. When the pain finally prevented me from playing, I saw an orthopedist who …

Tales of two nights before hip surgery

Hans Duvefelt, MD

Physician

October 23, 2013

On a hot afternoon in July Harold “Junior” Bray walked around his small farmhouse one last time before it was time to leave for the hospital. Everything was in order — the coffee maker was unplugged, the windows secure and the message on his brand new answering machine informed callers that he would return their call as soon as his health permitted.

Every step was deliberate, slow and painful. Whenever he …

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Tales of two nights before hip surgery

Pay for performance: Not everything that can be counted counts

James Marroquin, MD

Health Policy

October 17, 2013

There is a lot of talk these days about changing our health care system from “pay for volume” to “pay for value.” The idea is that we currently reimbursement doctors and hospitals according to the number of services delivered rather than how well they make us. This perverse system of incentives results in runaway health care spending that doesn’t necessarily result in a more healthy citizenry.

There is certainly truth in …

Necrotizing fasciitis: A case study and discussion

Adam Bitterman, DO

Conditions and Diseases

September 21, 2013

Necrotizing fasciitis is a rare but life-threatening soft tissue infection. Its presentation is characterized by rapidly spreading inflammation and resultant death both of the surrounding soft tissue and fascial planes. Prompt recognition and aggressive treatment is paramount in order to avoid fatality. Often times, symptoms may overlap in their presentations so one must maintain a high index of suspicion and a multidisciplinary approach facilitated appropriate imaging studies and resulted in a …

My patient experience wasn’t an outlier

Ashish Jha, MD, MPH

Physician

September 20, 2013

On a warm and sunny August Sunday, I was rollerblading with my kids on the Shining Sea Bikeway. On mile nine on the trip, I hit a tree root, went flying, and landed on my shoulder. I could tell immediately that something was wrong — I couldn’t move my arm and was in the worst pain of my life. Feeling for my left shoulder, it was obvious that I had …

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My patient experience wasn’t an outlier

The fall and recovery of a cardiac surgeon

Larry Zaroff, MD, PhD

Physician

August 26, 2013

Four months after having a knee replacement, I stumbled into the bathroom at 3am, not fully awake, hoping to urinate.

Losing my balance, I fell. The result was a compound fracture of my left leg — the one with the prosthetic knee.

Gazing at my shiny white kneecap, I lost all logic, all control. I simply cried.

At eighty, I was unprepared for this unexpected anatomy lesson: my twenty-nine years as a surgeon …

Injections for back pain: The evidence is weak

John Mandrola, MD

Conditions and Diseases

July 25, 2013

It’s been a while since I did a cycling topic.

As I was skimming thorough the Journal of the American Medical Association recently, I came across this review article on spinal injection therapy for low back pain. It was a shocker.

Two factors brought my attention to the article. First, almost all the cyclists or runners I know have been beset with either back pain or sciatica (referred pain or weakness down the leg). In …

How to know whether alternative medicine is safe

Juliet K. Mavromatis, MD

Medications

July 14, 2013

Recently a patient of mine brought in a bottle given to her by her acupuncturist. She had turned to acupuncture with my encouragement after traditional medicine fell short at addressing her chronic pain. Indeed, there is data to support the efficacy of acupuncture in the management of chronic pain. I was encouraged to hear that this treatment, often labeled as “alternative,” seemed to be helping her substantially.

However, my patient’s questions …

What I’ve learned from calling out my orthopedic colleagues

John Schumann, MD

Physician

June 19, 2013

Six months ago I posted a story about a demented 94-year-old patient who’d fractured her hip. She’d lost more than thirty pounds in the preceding months and had already had a collarbone fracture from a previous fall.

Her son wanted her to be made comfort care only, and avoid a trip to the operating room since she was likely within six …

Who should be able to certify medical necessity?

Marjorie Stiegler, MD

Physician

May 25, 2013

These days, there is a lot of talk about expanding scopes of practice for the group of folks who used to be called physician extenders and then midlevel providers and more recently non-physician providers, many of whom are now getting degrees with the title “doctor” incorporated.

While it seems to vary, these folks may include nurses, physician assistants (one day to be called physician associates perhaps), pharmacists, and more. Lots …

MKSAP: 52-year-old man with gradually progressive left knee pain

mksap

Conditions and Diseases

May 4, 2013

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 52-year-old man is evaluated for a 5-year history of gradually progressive left knee pain. He has 20 minutes of morning stiffness, which returns after prolonged inactivity. He has minimal to no pain at rest. He reports no clicking or locking of the knee. Over the past several months, the pain has limited his …

A reminder to slow down and focus on the human being

Audrey Cortez, RN

Patient

April 4, 2013

Years ago I worked as a registered nurse in a busy surgical pre-admission clinic, preparing patients who’d been scheduled for surgery for the upcoming operation and hospital experience.

My workdays were packed with back-to-back, hour-long appointments. Whatever surgery the patient was facing–oral, orthopedic or anything else–every interview followed the same format. I would greet the patient, who’d often bring along a family member, and quickly escort them both into my small …

Let no broken hip go unfixed: When a surgeon fails to communicate

John Schumann, MD

Physician

March 10, 2013

She was 94-years old with advanced Alzheimer’s. She thought it was 1954 and asked if I wanted tea. Not a bad memory for someone in a hospital bed with a broken left hip.

She’d fallen at her assisted living facility. It was the second time in as many months. She’d broken her collarbone on the previous occasion.

Over the past year, she’d lost 30 pounds. This is natural in the progression of …