Penn Orthopaedics

Penn Orthopaedics

Tuesday, November 17, 2015

Advances in Throwing: Latest on Injury Treatment and Performance Optimization

Join us for a dynamic, one-day conference to learn about the latest tools and techniques for treating throwing athletes. Through a series of panels, presentations, and debates, we will discuss a wide range of topics designed to advance injury treatment and optimize performance for throwing athletes.

Event Details

Date: Saturday, January 23, 2016
Time: 8:00 a.m. - 5:00 p.m
Location: Biomedical Research Building Auditorium
                University of Pennsylvania
                421 Curie Boulevard
                Philadelphia, PA

Featured Lectures:

Keynote Address - W. Ben Kibler, MD, FACSM
Dr. Kibler (Lexington Clinic Orthopedics) is the medical director at the Lexington Clinic and a former vice president of the American College of Sports Medicine.

How to Keep Pitchers Pitching – Phillip Donley, PT, ATC, MS
Mr. Donley (Optimum Physical Therapy Associates, PC ) has practiced physical therapy in the Philadelphia region since 1957, authored numerous papers, and has been a consultant with the Phillies for 10 years.

Disabled throwing shoulder – cause, prevention and why slap tears fail. - Craig D. Morgan, MD
Dr. Morgan (Morgan Kalman Clinic) has cared for Major League Baseball pitchers, Olympic-level athletes and golfers on the LPGA.

Who should attend?
This program is intended for athletic trainers, coaches, physical therapists and physicians. Registration fee includes breakfast and lunch:
  • Athletic Trainers / Coaches: $100
  • Physical Therapists: $150
  • Physicians: $200
Attendees are eligible for:
  • Seven (7) CEU's for Athletic Trainers
  • Seven (7) Contact hours for Physical Therapists

Wednesday, November 11, 2015

Serving Wounding Warriors

In 1918, in the 11th hour of the 11th day of the 11th month, the armistice marked the end of World War I. This infamous day in history also marked the origin of Veteran’s Day.

John L. Esterhai Jr., MD
While Memorial Day honors those who died in active military service, Veteran’s Day honors all who have served in the U.S. Armed Forces, living and dead.

These men and women that have given so much for our country deserve access to top-notch health care that addresses issues with which they may struggle—physical or otherwise.

John L. Esterhai Jr., MD, a Penn Medicine orthopaedic surgeon and chief of orthopaedic surgery at the Philadelphia Veteran’s Affairs Medical Center (PVAMC), knows this all too well. Dr. Esterhai is a veteran, having served in the Air Force as a flight surgeon stationed in Okinawa, Japan during the Vietnam War.

For him, and other physicians who volunteer at PVAMC, care for veterans goes far beyond just Veterans Day.

How Penn Medicine and the PVAMC Help Veterans

Together, Penn Medicine and the PVAMC provide access to health care for nearly 90,000 veterans living in and around the Philadelphia area.

“We take care of a lot of people who come a fair distance because they need care specifically for service-related injuries or simply because we’re their preferred provider,” he explains.

Healing the Deepest Wounds

The orthopaedics team at the PVAMC provides services that range from total joint replacements for aging Vietnam veterans to fracture care and sports medicine care for veterans from more recent wars.

From a physical perspective, some injuries are more challenging to overcome than others.

“One of the most debilitating issues is when the folks who have already lost a limb need to have the amputation revised,” says Dr. Esterhai.

He explains that the need for revision may be because of infection, healing difficulty, chronic pain, or the inability to use prosthesis because of limb damage. This obstacle on the path to physical recovery after losing a limb can keep them from moving forward with their lives.

But Dr. Esterhai says that helping veterans return to civilian life transcends orthopaedic care.

Many patients have had closed-head injuries because of the blasts from improvised explosive devices. And many come back with post-traumatic stress disorder from the situations that they’ve been in overseas.

“We at Penn are available to help so many other damaging effects of being a war fighter,” says Dr. Esterhai.

The Power of Empathy

Dr. Esterhai says empathy and the ability to relate to veterans on a human level is a critical part of their care.

“It’s easy to become a surgical technician who can fix something but then really doesn’t relate well to the patient, and the veterans are very sensitive to that,” he says. “It takes extra time in the office to listen to what a veteran says and to have some empathy.”

But it’s worth it. The physicians who provide care for veterans know that those few extra moments can go a long way in healing the wounds of those who have sacrificed so much for the safety and well-being of others.

Wednesday, October 28, 2015

The Benefits of Penn’s Joint Replacement Pain Protocol

Penn Medicine has implemented an innovative pain management system called MP3 (Multimodal Perioperative Pain Protocol) for joint replacement patients. In its simplest form, it means the use of different types of analgesic drugs as pain management to ensure that patients experience as little pain as necessary.

The MP3 pain management process delivers a personalized dose of pain-killers and anesthesia before, during and after surgery that work together in harmony to provide the most effective pain control.

 By using a personalized dose of analgesics, the patient benefits in multiple ways. The combination of medications makes them work more efficiently, thus reducing pain more quickly. Also, patients are receiving smaller doses of specific analgesics, thus reducing the unpleasant side effects some may cause.

The MP3 process begins even before administering any painkillers or anesthesia. Before surgery, the surgical team maps out the pain management plan, taking into account the patient’s unique attributes and any previous experiences with pain management including any side effects or adverse conditions. By understanding the patient and knowing what has occurred in the past, the team can better plan to avoid any negative side effects.

Administering analgesia before surgery is an integral part of pain management.

During the procedure, regional anesthesia is used. This has been demonstrated to reduce length of stay after surgery.

The multimodal process after surgery allows for a reduction in opioid usage and again reduces the risk of side effects. Because the team maps out the pain management plan prior to surgery, patients have seen improved sleep and a decrease in incidents of chronic postoperative pain.

In short, Penn’s MP3 pain management process is a clinically proven system shown to improve movement and reduce chronic pain post-surgery while also limiting the risk of becoming addicted to pain-killers during recovery.

The Penn Musculoskeletal Center

The Penn Musculoskeletal Center is a team of doctors, nurses and physical therapists who take a whole-body approach to diagnosing and treating joint pain. These experts work together as a seamless unit to provide a wide range of treatments, not just surgery, and help you return to an active, pain-free lifestyle.

Minimally-Invasive Approaches to Hip Replacement

For those suffering from severe hip pain, surgery may be the best treatment option. Depending on factors, such as age and overall condition of your hip, there are several surgical treatment options.

When possible, Penn Musculoskeletal surgeons perform minimally-invasive hip replacement surgery. The smaller incisions allow the surgeon access to the hip joint while preserving muscle function, enabling patients to return more quickly to their favorite activities.

In the video below, Charles L. Nelson, MD, Chief of Penn's Joint Replacement Service, discusses minimally-invasive approaches to hip replacement surgery and how they are performed at the Penn Musculoskeletal Center.

The Penn Musculoskeletal Center

The Penn Musculoskeletal Center is a team of doctors, nurses and physical therapists who take a whole-body approach to diagnosing and treating joint pain. These experts work together as a seamless unit to provide a wide range of treatments, not just surgery, and help you return to an active, pain-free lifestyle.

Chronic Knee Pain Over 50: Is Knee Replacement The Only Option?

Our bodies are like machines. As you start climbing the hill to age 50—and going over it—your parts starts to wear down. Eventually, they may require tune-ups or replacements.

Charles Nelson, MD
Charles Nelson, MD
Your knees are particularly susceptible to wearing down over time, since they bear much of your body weight. When this happens, you can either use painkillers and cortisone shots to buy time—or just go in to discuss a repair or replacement part.

Charles Nelson, MD, Chief of Joint Replacement Service at the Penn Musculoskeletal Center, discusses chronic knee pain for individuals over 50 years of age and whether knee replacement is their only option.

What percentage of your patients for knee surgery is over age 50?

Dr. Nelson: I suspect that around 65 percent are over the age of 50. There is no doubt that the patients under 50 are increasing, though. That’s just not in our practice. There are trends all over the country that demonstrate an increase in joint replacement in patients under 50.

For your patients over 50, how does knee pain affect their quality of life?

Dr. Nelson: It depends on the severity. In some extreme cases, we see patients that can’t walk at all. They may be completely limited to the point where they have a chair lift that takes them up and down the stairs, and they get wheeled around in either a manual or motorized wheelchair.

In most cases, people aren’t limited to that degree. But they might have pain doing things they used to enjoy. So, instead of going to church, they may listen to a service on Sunday on the television or radio and not socialize or attend activities they used to.

People will cut activities out of their lives just because they fear the pain they may experience during or following the activity.

Let’s say your patient has tried the over-the-counter medications, prescriptions and injections. Now, it’s time to talk about surgery. Is knee replacement the first thing you recommend for people over 50?

Dr. Nelson: I think knee replacement is a personal decision for the patient. It depends upon the circumstances and where the disease is.

In some cases, the arthritis is localized to a single area of the knee, meaning that a partial joint replacement may be more appropriate.

knee pain
There are a number of different knee injuries and other soft tissue conditions, some of which can get better on their own or with physical therapy.

Others that don’t get better on their own require knee repairs. One common procedure is arthroscopic surgery, where a small camera is used to identify and treat the damaged area of the knee.

If they’re younger and have good surrounding cartilage with a specific defect, then sometimes you can repair that defect with cartilage cells from the person. This is called a cartilage transplantation. Or you could repair it with fibrocartilage from their own bone marrow.

But again, it is a complex scenario because it’s really based upon the specific issues related to that individual patient.

What are some non-surgical alternatives to knee replacement?

Dr. Nelson: They can put less pressure on their knee. That can involve weight loss if they are overweight or it can involve the use of a cane, crutches or walker. They can offload their knee with a brace.

They can also take anti-inflammatory or analgesic medications to decrease their pain. They can do injections of either an anti-inflammatory medicine like a corticosteroid or they can undergo a joint lubricant injection.

What Patients Must Consider

What’s important for your patients to understand when evaluating any of these options?

Dr. Nelson: I think it’s important to have realistic expectations. I would encourage people to speak to others who have been through that type of intervention to see whether that’s something that makes sense for them.

I think trying to get as much information as possible from other patients who have been through it can be very helpful. And if it’s someone they are close to and have a bond with and trust, all the better.

If you’re over 50 and unsure whether a knee replacement is the next step, schedule an appointment with a specialist at the Penn Musculoskeletal Center.

Not ready to see a specialist? Learn more about the Penn Musculoskeletal Center

Friday, October 23, 2015

Knee Cartilage Repair: How Cartilage Injuries Are Like Potholes

James Carey, MD
James L. Carey, MD, MPH
Imagine driving along a busy four-lane highway after a harsh winter. High traffic, snowplows and salt trucks were constant for weeks on end. Now that warmer weather has arrived, all that remains are potholes.

This is basically what happens when you injure the cartilage in your knee, says James L. Carey, MD, MPH, Director of the Penn Cartilage Center.

Cartilage is the shiny surface that coats our bones and allows them to glide at the joints. It requires repair after damage, much like roads after long periods of abuse. Cartilage on cartilage is 1,000 times more slippery than ice on ice.

Dr. Carey explains the similarities between knee cartilage injuries and potholes, and what the road to repair looks like.

Some are minor, some are major

Not all potholes are equal. The same goes for cartilage injuries. There are two types: a focal defect and a regional defect. And each requires a different treatment course.

“When there’s a focal defect, like a small pothole on a good road, we can repair it,” Dr. Carey says. “But when the defect is regional, where all of the cartilage is lost on the surface, the joint gets replaced, like a total road resurfacing. They are kind of on a continuum because little potholes can turn a street into a bad road.”

Damage occurs over time

Just as potholes do not appear overnight, cartilage injuries take time to develop. This process is called repetitive microtrauma.

Simply going up and down stairs over and over again can lead to wear and tear of cartilage,” Dr. Carey says. “You may experience discomfort here and there. But, over time, it becomes painful all the time.”

“Sometimes, it’s not until there’s a loose piece of cartilage - or the pothole is totally uncovered - that you become symptomatic,” Dr. Carey adds.

One condition caused by microtrauma is osteochondritis dissecans, where part of the cartilage or bone separates from the knee.

Treating knee cartilage injuries is important

The same rule applies to cartilage injuries. “As the lesions in cartilage get larger in size, the outcomes from treatment become less predictable,” Dr. Carey says.

Unfortunately, along with less predictability comes a host of problems.

As Dr. Carey explains, cartilage damage can limit a person’s motion to the point where the knee cannot bend or straighten completely. Or during movement, a person will have “catching sensations—where motion of the knee is temporarily inhibited—or locking sensations—where motion of the knee is halted,” he says.

Pain and swelling are common as well. Resting for a week or two can help, but often that’s not a long-term option, he says: “People who play soccer or lacrosse want to continue to play soccer or lacrosse. They don’t want to switch to chess or checkers.”

That’s why early treatment is important. You don’t want to wait too long because you may create more problems down the road.

It’s like driving on a road littered with potholes. You can dodge them as best you can, but you’re bound to blow out a tire eventually.

In part two: Dr. Carey outlines the treatment options available to repair knee cartilage.

Wednesday, October 14, 2015

Is Knee Cartilage Repair Right for Me?

In part one, we explained how cartilage injuries are like potholes. In part two, we’ll explore the treatment options available for knee cartilage repair.

You probably take for granted how well your knees work. Our joints allow us to move effortlessly.
James L. Carey, MD, MPH
James L. Carey, MD, MPH
But in the process, they endure a lot of wear and tear—particularly in the knees. This is why as you get older, you start experiencing pain.

When the smooth surface called cartilage that coats our bones has a defect, treatment is required.

James L. Carey, MD, MPH, Director of the Penn Cartilage Center, explains what treatment options are available for knee cartilage repair.

Size Matters

A patient’s treatment options depend on the size and location of the defect. Generally speaking, Small defects in specific locations may be treated using an osteochondral autograft transfer or a microfracture, which can be performed with smaller incisions.

Osteochondral autograft transfer
This procedure involves borrowing a little piece of cartilage and bone from a less critical part of the knee and putting it in a more critical part.

“As you can imagine, most of our cartilage is pretty critical or it wouldn’t be there,” Dr. Carey says. “So, there are limits to how much we can borrow. That’s why this can only be used for small defects, usually less than two square centimeters.”

During microfracture, “little holes are drilled in the bone to allow the marrow to leak out,” Dr. Carey explains.

cartilage regenerationThis is because “marrow cells are special cells. They can go down many pathways. One pathway is cartilage, which is what we want. It fills the defect and patches it,” he says.

Larger defects may be treated using autologous chondrocyte implantation (ACI) or osteochondral allograft transplantation, both of which require open incisions.

Autologous chondrocyte implantation (ACI)
ACI is a two stage treatment. The first stage is done arthroscopically. This means only two small incisions are made.

“A little biopsy of cartilage—about the size of a Tic Tac—is harvested and sent to a laboratory, where they grow millions and millions of the patient’s own cells,” explains Dr. Carey.

“Then, about three to five weeks later, they send back vials of the patient’s own cells—about 12 million cells per vial,” he adds.

The second stage is an open procedure with an incision long enough for access to the injury site. 

During this procedure, a collagen membrane is sewn around the surrounding cartilage, Dr. Carey says. “The cells are then injected underneath the membrane and sealed watertight, so that the cells don’t leak out.”

The cells mature over time—as long as 18 months—and become cartilage, he adds.

Osteochondral Allograft Transplantation
“This procedure is like a heart or lung transplant, but for cartilage and bone,” says Dr. Carey.

During the procedure, the damaged cartilage or bone is replaced with the donor tissue.

Dr. Carey adds that you don’t have to worry about matching donors based on blood type like you do with organ donation. Instead, bone and cartilage are generally matched based on size.