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Head, Shoulders, Knees and Toes


Orthopaedic Surgeons Shed Insight into Industry Changes, Improvements

The catchy children's song "Head, Shoulders, Knees and Toes" could also be an anthem for Middle Tennessee's prolific orthopedic practice environment that offers specialized care from top to bottom. From providing cutting-edge care for professional athletes to watching out for weekend warriors, area orthopaedists utilize the latest techniques to get patients back in the game.

Innovation in Care

J. Craig Morrison, MD>

"The biggest innovation isn't what's being done in surgery but perioperatively around surgery, which is improving the continuum of care," said J. Craig Morrison, MD, orthopaedic surgeon at Southern Joint Replacement Institute (SJRI).

That includes centralization of preparing patients medically and educationally long before surgery. "We want to make sure they're aware of what they're getting into and that they're optimized for surgery in every way," said Morrison, noting evolution of pain management options such as peripheral or spinal blocks rather than general anesthesia.

In the face of a nationwide opioid epidemic, doctors also are adopting multi-modal pain regiments to attack post-surgical pain from a variety of angles while targeting different pain receptors. Blood loss concerns have also been mitigated thanks to widespread use of tranexamic acid - a drug that stabilizes formed blood clots and reduces active bleeding, greatly diminishing the need for transfusion. Robotic-assisted and computer-navigated procedures have also inundated the market in the past decade.


Andrew J. Gregory, MD, FAAP

Concussion treatment has come a long way in recent years. Andrew J. Gregory, MD, FAAP, co-director of the Vanderbilt Sports Concussion Center, said the "zero stimulation" theory still practiced by many doctors and parents has fallen by the wayside in favor of newer findings. "People used to advocate complete rest and putting someone in a cold dark room with no stimulation, but we've learned that no stimulation is bad for people and can actually make symptoms worst," said Gregory, who serves as team physician for Nashville Christian School, Vanderbilt University, the Nashville Soccer Club and USA Volleyball National Teams. "Getting people back to physical activity after a few days of rest is good for recovery and actually speeds it up."

Gregory said concussions should be followed by a day or two of rest before starting light physical activity as recommended by a physician. Gregory recommends providers put patients on a treadmill after one or two days to gauge exertion levels before symptoms develop. The test provides a starting point as to how much exertion is acceptable, and exertion levels can be increased.

Concussion symptoms range from sleep problems to headaches, cognitive difficulty, balance or eye trouble or emotional problems. Balance, ocular or cognitive therapy are beneficial for those whose symptoms persist for more than a month. According to Gregory, 90 percent are better within the first three weeks. "We want patients to return to activity quickly, even if it's just walking or using an elliptical," he said. "Research in the last year has proven that recovery is faster when you become active sooner."


Robert Landsberg, MD, FRCS

Robert Landsberg, MD, FRCS, of Landsberg Orthopaedics in Hendersonville, said the shoulder's unique ball-and-dish design puts the joint at higher risk for injury and dislocation. When exercises, splinting and injections no longer control pain, patients often opt for arthroscopy, reconstruction of the rotator cuff or total shoulder replacement.

"Total shoulder replacement has been around since the 1970s, but the main improvements over the years have been in design and technique," Landsberg said, noting popularity of the reverse total shoulder in recent years.

"Total shoulder replacements aren't just for arthritis now but for older adults who have no rotator cuff and need a reverse total shoulder." Considered an end stage procedure, reverse total shoulders entail putting the ball on the socket side and the socket on the humeral side to create more constraint. That's because the reverse total shoulder replacement relies on the deltoid muscle, instead of the rotator cuff, to power and position the arm. Partial shoulder replacement (involving only the ball or humeral head) provides a faster recovery and is often an effective solution for younger patients with arthritic shoulders.

Computer navigation for shoulder replacement is currently dominated by ExactechGPS, whose 3D planning software allows surgeons to better position the socket by mapping the perfect position ahead of time. "The biggest difference is that we're able to better handle larger bone deformities with more confidence and efficiency, which leads to more accurate placement and better survivorship," he said.


David DeBoer, MD

SJRI's David DeBoer, MD, performs nearly 400 knee replacements each year. He said one of his most valuable tools is a database of the group's 8,000-plus joint replacement patients that allows him to track which procedures have yielded the best outcomes. "We collect so many details about patient characteristics and each surgical procedure, from pain scores to functional results, so that we don't make changes without knowing for certain that we're improving quality of care, whether that's choosing a different implant or technique," he said.

Compared to traditional knee implants, today's medial pivot knee implants more closely match normal knee kinematics - natural movement of the joint. And better material means implants are now lasting 15 to 20 years.

"Implants have gotten better, and today's knees help patients regain normal stability for higher demand activities like tennis, golf or skiing," said DeBoer, noting the increasingly younger demographic of today's joint replacement patients. "Patients today are living longer and are extremely active," he said. "Those combinations and improvements in joint replacement have led to more innovation and medical attention for treatment of arthritis at younger ages."

William Shell, Jr., MD

Nationally, the average age of joint replacement patients is around 65 - a testament to an active baby boomer population refusing to grow old in a rocking chair. William Shell, Jr., MD, orthopaedic surgeon at Tennessee Orthopaedic Alliance, said patients not only expect pain relief but also want to regain a high level of function.

"Implant design continues to evolve," Shell said. "Total knees historically do not replicate normal knee mechanics, but we now have patient-specific implants manufactured to fit each individual patient. This technology may be the best marriage of navigation/robotics and implant design. We have gait lab studies demonstrating knee kinematics with these knees similar to a normal knee."

Considering the younger and more demanding patient population, coupled with a rising incidence of heavier patients, Shell believes there will be a renewed interest in cementless implants. "We know bone cement will fatigue over time leading to implant loosening," he explained. "Ingrowth of the implant to bone eliminates that concern and may result in greater longevity of the replacement."

When treating younger patients, surgeons like Landsberg also restore articular cartilage in the knees by performing a graft transplant. "A 25-year-old is too young to receive a total knee, so we replace the joint surface using a fresh allograt (donated cartilage transplant)," he said. Landsberg also biopsies and cultures the patient's own cells, allowing them to and receive their own articular cartilage.


Geoff Watson, MD

Geoff Watson, MD, orthopaedic surgeon at the Bone and Joint Institute of Tennessee, said surgical foot and ankle innovation is on the rise. Watson is now performing cartiva implants to resolve joint pain in the big toe - a welcome alternative to fusion.

"The implant is a spacer shaped like a gum drop, and it's synthetic cartilage to hold the joint open," he explained. The implant is proving effective at preserving motion while reducing pain.

Achilles tendon repairs have also received an upgrade: Watson said 1-inch percutaneous incisions have replaced the four-to-five-inch incisions used in the past. Patients also are benefitting from advances in ankle replacements, first attempted more than 30 years ago.

"The original ankle replacements didn't do well, but the new ones have a 95 percent track record, providing a lot of pain relief and allowing for better motion," Watson said. "Ankle replacement is challenging because it's a smaller joint under a lot of stress, but innovation in surgery means we can help get patients back on their feet."


Vanderbilt Orthopaedics


Bone & Joint Institute

Landsberg Orthopaedics


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Andrew Gregory, Bone and Joint Institute of Tennessee, David DeBoer, Geoff Watson, J. Craig Morrison, joint replacement, Landsberg Orthopaedics, Robert Landsberg, SJRI, Southern Joint Replacement Institute, Tennessee Orthopaedic Alliance, TOA, Vanderbilt Sports Concussion Center, William Shell
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