Peyton Manning—Wrong Surgery?…Mount Sinai Chief Breaks Down Tiger Woods’s Foot Problems…SPORT Study’s Surprising Results Reconsidered…Strange Bedfellows Make Progress at HSS Osteoarthritis Summit…and more….
Dissecting Tiger Woods’s Achilles Rupture
Tiger Woods’ recurring ankle injuries are certainly an Achilles heel for any pro athlete. Steven Weinfeld, M.D., chief of the foot and ankle service at Mount Sinai School of Medicine in New York, told OTW, “The type of injury that Tiger Woods is experiencing is extremely common in the weekend warrior, especially in sports where there are sudden starts and stops or cutting motions. The problem with a professional athlete like Tiger, however, is that a rupture of the Achilles tendon can cause a real downturn in their careers. Many football and basketball players never really come back from it; Patrick Ewing had chronic problems like this that precipitated the end of his career. Most likely, Tiger will recover. The question is, ‘Will he be able to perform at his normal level of excellence?’
Normally someone with Tiger’s injury would stop playing and would be put in a cast or a boot to rest the Achilles tendon. But this would take Woods out of the Masters. He’s probably going to try to play through the injury and immobilize it later—which makes sense given his situation. There is a low risk of tendon rupture if he plays through the injury, but the danger is that the symptoms could persist and worsen. If I were in charge of his care, and he wanted to play through the injury, then we would use any modality anti-inflammatory, along with external support. Physical therapy with ultrasound would help quiet any inflammation, while a lift in the shoe could help as well. These things can take a very long time to heal…we just won’t know about Tiger’s career for awhile.”
Strange Bedfellows Make Progress at HSS Osteoarthritis Summit
What if you locked clinicians, researchers, insurers, device manufacturers and others all in the same room for a good cause? Progress! Tim Wright, M.D., Kirby Chair of Orthopedic Biomechanics at Hospital for Special Surgery (HSS) was co-chair of a recent landmark event at HSS: the Osteoarthritis Summit: Frontiers in OA research, Prevention, and Care. Dr. Wright told OTW, “While there is a history of events focused on osteoarthritis, these typically included only researchers and clinicians. We brought together all possible stakeholders for the first time: researchers, clinicians on the orthopedic surgery side, clinicians from rheumatology, device and pharmaceutical reps, and insurers.
What is evident is that there are two effective treatments—and a fair amount of research to back them up—weight loss and moderate exercise. It’s hard for the insurers to get their arms around these, however. But we did have a great discussion about how we could provide the data that could be used by providers to justify weight loss and exercise programs. There was a sense of frustration among clinicians and researchers in trying to understand the level of evidence we would need to prove in order to get things approved. Ideally, insurers will start incentivizing their members to lose weight and exercise for orthopedic reasons (as they do now with diabetes or heart disease). John Hardin, Arthritis Foundation VP of Research, challenged us to begin thinking about just getting base hits…that we don’t want to try for a home run in taking on OA, because it’s not the most effective way to make progress. For example, we know that post traumatic arthritis often happens after a meniscal tear. With John’s approach, we’d say, ‘What can we understand about that scenario? Maybe we can impact the injured cartilage right after the trauma…maybe that is a place to start. The folks from industry thought that this was an intriguing approach.”
Peyton Manning – Wrong Surgery?!
We’ve heard some buzz from several orthopedists saying that Peyton Manning underwent the wrong operation…so we checked with a prominent orthopedist who has experience from the neurosurgical end of things. When asked if Peyton Manning had the wrong surgery, Neel Anand, M.D., director of Spine Trauma at the Cedars-Sinai Spine Center in Los Angeles, told OTW, “Absolutely not! The issue seems to be weakness of the triceps in his throwing arm. The surgeons had to open things up and give the nerve some room. And once you take the pressure away the hope is that the cells should wake up and be normal…but those cells may not…and there is really no specific way of knowing how they will behave. Maybe some of my colleagues think he had the wrong surgery because orthopedic surgeons are not used to doing posterior cervical foraminotomies—that has traditionally been the terrain of neurosurgeons. Peyton Manning’s surgery has nothing to do with his future…his future probably depends on his ability to throw and on the recovery of function in his triceps. This is a subjective thing that nothing but time and Peyton Manning himself can determine; it is up to the nerve…the nerve decides.”
Peter G. Trafton, M.D. Joins U.S. Bone & Joint Initiative
According to an AAOS Now report, Dr. Peter Trafton has been named to the board of directors for the U.S. Bone and Joint Initiative. Dr. Trafton, who is a past president of the Orthopaedic Trauma Association, previously served as the orthopedic trauma chief and director of the orthopedic trauma fellowship at Rhode Island Hospital in Providence. He is currently a consultant and teacher at Brown Alpert Medical School in Providence, R.I. He earned his medical degree at Harvard University in Boston.
Christopher Raffo, M.D. is Top Doc in Washington, D.C.
Washingtonian Magazine has named Dr. Christopher Raffo, a physician who specializes in the care of adult and pediatric athletic injuries, as top orthopedist for 2012. Dr. Raffo completed a residency in orthopedic surgery at Georgetown University. He completed an additional year of fellowship training in advanced arthroscopic (minimally invasive) techniques for shoulder and knee surgery, at the New England Baptist Hospital, a Harvard affiliate hospital. Recently, Dr. Raffo received his board certification in sports medicine…something which is only an option for those certified orthopedists who are fellowship trained and whose practices primarily consist of sports medicine.
SPORT Study’s Surprising Results Reconsidered
Tom Errico, M.D., Chief of the Spine Service at NYU Hospital for Joint Diseases, was a co-author of the Spine Patient Outcomes Research Trial (SPORT) article in the New England Journal of Medicine on degenerative spondylolisthesis. He’s been thinking a lot lately about degenerative discs and what drives patients to surgery. Dr. Errico told OTW, “The SPORT study continues to be a valuable source of information for those of us in spine care. A recent study from the Rothman Institute—which utilized SPORT data—found that patients who had epidural steroid injections (ESI) had a higher rate of crossover to surgery and had worse outcomes compared to those who did not receive ESI. I noted this with interest. With degenerative spondylolisthesis in general the thing that drives patients to abandon conservative care and head to the OR is the claudication and leg pain component of the problem.
Looking at the SPORT study, we saw that another interesting driver of cross-over was the overall level of patients’ disability. Patients with Oswestry Disability Index (ODI) scores under 40 who randomized to surgery rarely had their surgery. Patients with ODIs above 40 randomized to further conservative care more frequently crossed over to surgery because of their disability level. I therefore wonder if patients in SPORT with a more progressive and disabling condition (especially leg pain) were not prescribed epidural steroidal injections (ESI) with a higher frequency—which might explain the higher cross over rate of surgery unrelated to the ESI.”
