Orthopedics, Spine & Sports Medicine

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Emory Plays a Key Role in Accelerated Bone Healing

May 13th, 2011 By Dr. Boden

Dr. Scott Boden Emory Healthcare At Emory Healthcare, we’re always looking for new and better ways to treat patients. Bone healing, particularly after spine fusion surgery, is one of the many areas in which we’ve pioneered research that can significantly improve our patients’ quality of life. For more than two decades, the Emory Orthopaedics & Spine Center has been instrumental in developing technology to improve bone healing, accelerate the speed of healing, and prevent the need to “borrow” bone graft.

While some broken bones heal quickly and easily, certain types of leg bone fractures and high energy traumatic fractures often need extra help. In some cases, bone graft has been used in the treatment of difficult fractures, segmental bone loss, and fusion of other joints in the body that may have severe arthritis (e.g., foot joints). At Emory, spine fusion represents 50% of the reason our surgeons would harvest bone graft in the past. Many spine operations involve getting bone to grow in the spine, where it normally doesn’t grow. Also, for certain types of long spine fusions, there’s often not enough bone. Traditionally, the surgeon would harvest bone graft from the patient’s hip (pelvis). This process, called an iliac crest bone graft harvest, often causes patients to complain of chronic pain at the bone donor site.

So how do we accelerate bone healing and avoid the use of bone graft? Emory has participated in laboratory studies and clinical trials to work out the details of how to use special proteins in humans. The first procedure was approved by the FDA in 2002. The approval is for only very specific indications, so work is ongoing to optimize these proteins for more broad use. Since we at Emory are very familiar with the science and development of these proteins, we’re able to use them safely in a variety of individual patient cases. In some situations, use of these proteins can prevent the need for bone graft harvest from the hip and result in better healing.

Some of the newer bone-healing technologies have only limited approval by the FDA and can be associated with some local side effects, so their use is not as broad unless they are being used by a very experienced surgeon or as part of a research trial—such as those conducted at Emory. Over the next five to 10 years, you can expect these new bone healing technologies to be more commonly used. If you’re having surgery at Emory that requires bone grafting or bone healing, ask your surgeon whether bone healing technology is a viable option for you.

Have you had a bone graft or surgery using new bone-healing technology? We welcome your questions and feedback about accelerated bone healing in the comments section below. For more information on accelerated bone healing technology at Emory, watch the short video below:

About Dr. Boden

Scott D. Boden, MD, Director of the Emory Orthopaedics & Spine Center and Professor of Orthopaedic Surgery, is an internationally renowned surgeon, lecturer, and teacher and the driving force behind the Emory University Orthopedics and Spine Hospital (EUOSH). Dr. Boden started practicing at Emory in 1992.

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Orthop(a)edics 101

April 6th, 2011 By Emory Orthopaedics & Spine Center

Orthopedics 101 Is it “orthopaedic” or “orthopedic”? What does “musculoskeletal” really mean? What’s the difference between a ligament and a tendon? Today we’re going to answer some of the more pressing questions people have about this fascinating area of medicine.

First off, let’s discuss the use of orthopaedic v. orthopedic. Orthopaedic is derived from the Greek orthos, for correct or straight, and paideion, for child. Today, orthop(a)edics refers to the correction of spinal and bony deformities in both children and adults. In the U.S., we like to keep things simple, so “orthopedics” has become the standard spelling. In Great Britain and its other former (non-U.S.) colonies, orthopaedics is preferred. The academic world, like the Brits, enjoys fancying things up, so in most universities and other academic settings, orthpaedics stands. Microsoft Word prefers it without the “a.” Take your pick.

Simply put, orthopaedic (or orthopedic) surgery is the branch of surgery concerned with conditions of the musculoskeletal system. What’s the musculoskeletal system? Clearly, it’s a system that involves the muscles and the skeleton. Also called the “locomotor system,” the musculoskeletal system includes the parts of your body that help you move. And help you stay in one place. The bones provide stability, while the muscles help the bones stay in place and move. Joints allow motion, and cartilage keeps the bone ends from rubbing against one another. It’s all about how bones are connected to other bones and joints and muscles by connective tissues called tendons and ligaments.

What’s the difference between a tendon and a ligament, you ask? A tendon (or sinew) is a tough band of tissue that connects the muscle to the bone. A ligament connects bones to other bones. But wait—let’s not forget the fascia. The fascia is a layer of fibrous tissue that surrounds muscles and groups of muscles, as well as blood vessels and nerves, and binds all of these together. The layers of fascia include a superficial fascia (connected to the dermis, or skin), a deep fascia (surrounding the bones and muscles), and a subserous, or visceral, fascia (supporting the organs).

The surgeons and physiatrists at the Emory Orthpaedics & Spine Center are intimately familiar with every aspect of the musculoskeletal system and can diagnose and treat myriad ailments, both surgically and nonsurgically. So if you’re hurting, whether from a broken bone or a stretched or torn ligament or tendon, come see us. With or without the “a,” we know our orthop(a)edics.

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As an Academic Medical Center, Emory Provides Superior Spine Care

March 16th, 2011 By Dr. Boden

I am often asked questions like “Will YOU actually be doing my surgery?” and “Does a teaching hospital mean someone will be practicing surgery on my back?” These questions made me realize that many patients don’t understand what it means to receive care in an academic medical center, so I thought I would try to explain this in more detail.

Most of the differences in a true academic medical center, especially for a spine center, represent benefits that the patient may not even realize. First, to be a physician at an academic medical center, the surgeon also must be a professor, usually in a School of Medicine. As part of the medical school faculty, these physicians, in addition to taking care of patients, are teaching surgical techniques to the future generation of surgeons and/or performing research that is allowing for new discoveries and advancements in the field. This means that patients are exposed to the latest advances in surgical techniques and technology.

In addition, because of the teaching process, the patient will likely have a second MD assisting (helping retract and hold tissues), rather than just one surgeon and a nurse or surgical assistant. I would liken it to a pilot and co-pilot flying an airplane. Spine surgery is serious business, with little room for error, so you can rest assured that at any reputable academic center (such as Emory), the key portions of the surgery will be performed by your surgeon.

A second benefit comes from the collaborative environment in a multidisciplinary spine center. At the Emory Spine Center, one of the largest in the U.S., there are physical medicine/rehabilitation, occupational medicine, psychology, orthopaedic surgery, and neurological surgery physicians all seeing patients side by side every day. This spectrum of physicians ensures that no matter what a patient’s spine problem may be, he or she is sure to find a true expert among the staff. This environment takes the worry away from the patient about which type of specialist to see.

All of the surgical and nonsurgical physicians working at the Emory Spine Center have been fellowship trained (which means they’ve received extra training to specialize in spine care) and spend the majority of their clinical practice diagnosing and treating only patients with spine problems. This level of sub-specialization is harder to find outside an academic center. In addition, academic medical centers usually have the resources to have the latest and highest quality imaging technology—which is also very helpful in spine care.

A third benefit comes from the fact that some of the toughest cases are referred to academic centers. As a result, these physicians have more experience with the toughest problems and rarest complications, so that in the unlikely event you do experience a complication, they are very comfortable diagnosing and managing it to minimize any long-term impact on your outcome.

Most of these and other advantages of an academic medical center typically go on behind the scenes, which is probably why so few people truly understand the difference.

How have you benefitted from spine treatment in an academic medical center? We welcome your questions and feedback in the comments section below.

About Dr. Boden
Scott D. Boden, MD, Director of the Emory Orthopaedics & Spine Center and Professor of Orthopaedic Surgery, is an internationally renowned surgeon, lecturer, and teacher and the driving force behind the Emory University Orthopedics and Spine Hospital (EUOSH). Dr. Boden started practicing at Emory in 1992.

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Ironman Triathlete Back on Track after Lumbar Laminectomy

February 15th, 2011 By Dr. Yoon

When it comes to spinal disorders, there’s good news for the weekend warrior who enjoys vigorous athletic training and competitive sports activities. Being in great physical shape plays a large role both in your recovery and getting you back to an active lifestyle.

Joann Pope, one of my current patients, has an impressive athletic resume. She completed the half Ironman in Panama City, Florida, 21 times straight. She qualified for the world-famous Hawaiian Ironman seven times and finished four times. But two years ago, at the age of 74, her back started hurting and she had to stop racing due to lumbar spinal stenosis.

Lumbar spinal stenosis is a degenerative condition that causes a narrowing of the spinal column in the lower back, known as the lumbar area. This narrowing occurs when the growth of bone or tissue or both reduces the size of the openings in the spinal bones. This narrowing can squeeze and irritate the nerves that branch out from the spinal cord. It can also squeeze and irritate the spinal cord itself, causing pain, numbness, or weakness, most often in the legs, feet, and buttocks.

You might think that the physical stress of being a triathlete took its toll on Joann’s back, but that isn’t the case. In fact, if she hadn’t been in such great shape, her spine might have begun degenerating long before it did. For more than 20 years, Joann has been running, biking, and swimming. She was 47 when she started running, back in 1984. After she ran the Boston Marathon, her daughter talked her into doing a triathlon, the ultimate endurance test – a grueling three-part race with no stops.

So, thanks to her level of fitness, it’s as if Joann has the body of someone 20 years younger. Despite her active lifestyle , the lumbar stenosis progressed, and Joann’s pain, which came on slowly, continued to get worse.

Before Joann came to see me, she’d been experiencing lower back pain for a year. To address it, she’d been taking pain pills twice a day and was undergoing physical therapy, the first line of defense for lumbar stenosis. But when therapy didn’t ease her pain, her physical therapist told her she needed to see a surgeon. She chose to come to the Emory Orthopaedics & Spine Center.

In July of 2010, I performed a lumbar laminectomy and fusion on Joann. This procedure, also called a decompression, relieves pressure on the spinal cord or spinal nerve by widening the spinal canal. In Joann’s case, I removed the portion of the bony roof of the spine, or lamina, that was pressing on her lumbar nerves. Then I fused the two lowest lumbar vertebra, L4 and L5, with screws. When she woke up, the pain she had before surgery was gone.

Because Joann had been in such great physical shape before the surgery, she recovered rapidly and was swimming and walking again quickly. Now she’s walking two miles a day and is working up to getting back on her bike. Joann remains pain free and plans to go back to racing.

Have you had a lumbar laminectomy, or would you like to learn how spine surgery at Emory can get you back to the active life you enjoy? We welcome your questions and feedback in the comments section below.

About S. Tim Yoon, MD:
S. Tim Yoon, MD, PhD, specializes in minimally invasive surgery and cervical spine surgery. He is board certified in orthopedic surgery. Dr. Yoon started practicing at Emory in 2000.

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Top Four Ways PRP Therapy is Different at Emory Sports Medicine

February 3rd, 2011 By Dr. Amadeus Mason

Football fans are anticipating a competitive Super Bowl match-up between the Pittsburgh Steelers and Green Bay Packers this Sunday. Steelers’ fans might remember that the last time the Steelers were in the Super Bowl—in 2009— wide receiver Hines Ward was very close to being unable to play because of a sprained medial collateral ligament of his right knee. Fortunately, he was able to contribute to his team’s victory over the Arizona Cardinals with the help of a cutting-edge procedure called platelet-rich plasma (PRP) injections.

Since Ward’s high-profile recovery, PRP therapy has become a popular treatment for those suffering from ligament and tendon injuries—and Emory Sports Medicine has become a leader in the PRP therapy field.

Here’s how it works: PRP therapy is an outpatient procedure, in which blood is drawn and placed in a centrifuge for 15 minutes to separate out the platelets. The layer of platelet-rich plasma is then injected into the diseased portion of the tendon with the guidance of an ultrasound machine. Patients are then put on a program of relative rest followed by physical therapy for the first six weeks. After about 6 to 12 weeks, patients are re-evaluated for improvement. (Many patients require only one treatment.)

Sounds simple, right? It can be, but only if it’s performed properly and with the right expert guidance. Below we’ve outlined four factors that allow Emory Sports Medicine to excel at PRP therapy:

We’ve been doing this since the beginning. PRP therapy is a fairly new procedure, and Emory has two doctors on staff who are skilled in performing it: Dr. Kenneth Mautner and myself. Both of us are dedicated to keeping up with the latest developments in the field.
A vital step in the PRP process is the separating of platelets. We use only the most advanced centrifuge systems to ensure the highest concentration of platelets harvested from the process.
We use ultrasound guidance to place the PRP into the affected tendon. Many other practices don’t use ultrasound—and the difference can be compared to dropping an atomic bomb vs. using a laser-guided missile. Although utilizing PRP in a generalized area can be helpful, placing it in a specific area will give the best chances at a positive result, proper healing, and full recovery.
Emory Sports Medicine has developed a standardized post-injection protocol – a daily and weekly follow-up program designed to give patients the best chance at recovery.

While PRP therapy is still a relatively new procedure, when a skilled team of physicians does it properly, the results are remarkable. Just ask Hines Ward!

Are you considering PRP therapy? Do you have any questions regarding this procedure? If so, be sure to leave a comment here, or contact Emory Sports Medicine for an evaluation today.

About R. Amadeus Mason, MD:
Dr. Mason specializes in family practice and sports medicine. His areas of clinical interest include ankle, foot, shoulder, sports injuries, wrist, and ultrasound. Dr. Mason holds organizational leadership memberships with the American Academy of Family Physicians, the American College of Sports Medicine, and the Georgia State Medical Association.

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Ultrasound is Not Just for Babies Anymore

January 22nd, 2011 By Melanie Hof, MS, ATC

When most people think of an ultrasound, they imagine a pregnant woman getting a preview look at her baby’s fingers and toes while a doctor makes sure that all is well inside the womb—however, in recent years the medical field has found many new uses for ultrasound technology. At Emory Sports Medicine, where I work as an athletic trainer with Dr. Ken Mautner, we frequently use ultrasound diagnostics to pinpoint the causes of tendon and ligament pain. From time to time, Dr. Mautner even brings out the ultrasound as an aid in treating the injury.

Until a few years ago, the go-to test for diagnosing the cause of chronic tendon and ligament pain was an MRI. We still frequently use MRI at Emory Sports Medicine – it’s the best diagnostic tool in many situations – but more and more often we’re turning to diagnostic ultrasound to get a better picture of what is going on inside our patients’ bodies.

Ultrasound offers several advantages in diagnosing tendon and ligament injuries. One of my favorite advantages – and one our patients appreciate as well – is the instant gratification we get with an ultrasound. There’s no waiting for a report on an MRI that is just a static snapshot of one moment in time. You can point to where you’re hurting, and we can immediately get a look at that precise area, in real-time motion, as you’re moving and experiencing the pain. Dr. Mautner can show you pictures from the ultrasound right there during the appointment and explain to you what he sees. It’s always interesting to watch him take a picture that might first look like a confusing blob to most of us—then he explains the picture in such a way that patients can see what he’s seeing in it and understand what’s wrong. (I stick around after he leaves to answer any further questions patients might have about the ultrasound or their injury.) I love this aspect of diagnostic ultrasound. Often, in the span of a single appointment, we can hear what’s hurting, take a look at the affected area, find the problem, show it to you, and come up with a plan of action. It’s much easier for everyone involved.

Ultrasounds also allow us to look at injuries in greater depth, picking up very small tears that an MRI might miss. “Mystery pains” with no clear cause often reveal their secrets to the ultrasound. We’re seeing this quite a bit with hip pains, which have historically been very tricky to diagnose. Diagnostic ultrasound can look deep into the hip and the many crisscrossing tissues within it to find the source of the pain. Dr. Mautner even uses the ultrasound to guide treatment of the hip pain once the cause is found. Injections are often used to treat tendon and ligament pain, but they are notoriously difficult to administer precisely deep within the hip. Dr. Mautner uses ultrasound to guide him, in real-time, as he inserts the needle, delivering the injection to the optimal spot for healing.

The more we use diagnostic ultrasound, the more advantages we’re finding. Ultrasounds do not emit any radiation, so they are safe for people with pacemakers, spinal cord stimulators, and other medical devices that cannot handle the radiation of other diagnostic tools. And there’s no risk of feeling claustrophobic.

Just to be clear, ultrasounds are not replacing other diagnostic tools. For some injuries, an MRI or other test is the best approach, and Emory Sports Medicine has some of the finest, most innovative radiologists around. But for some injuries, we’re finding that ultrasounds are very helpful to us as we diagnose and treat the source of tendon and ligament pain.

And they’re still great for looking at babies, too!

Melanie Hof, M.S., A.T.C., is an athletic trainer at Emory Sports Medicine. She enjoys ultramarathon canoe and kayak racing, biking, and running.

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Repairing Cartilage Injuries with Cartilage Transplants

November 30th, 2010 By Dr. Labib

With another exciting football season well underway, athletes all over the country are putting enormous strains and stresses on their cartilage, the connective tissue between bones that absorbs shock and helps joints move smoothly. Cartilage is a remarkable tissue, but with such punishing forces applied to it, cartilage is sometimes damaged. A new procedure we’re studying at Emory Sports Medicine – cartilage transplantation – may offer an alternative approach to cartilage repair.

Cartilage damage is common in active people, particularly among those who play sports that involve lots of pivoting and twisting. Basketball, soccer, football… basically any sport involving a ball and running increases the risk of a cartilage injury, most commonly in the knees, ankles, and hips. In many cases, these injuries cause no serious, long-term problems. But sometimes a chip, divot, or hole in cartilage can cause significant pain and mechanical symptoms such as clicking, catching, and locking up of the affected joint.

Standard approaches to cartilage repair include scraping or smoothing the damaged cartilage, or poking a hole in the underlying bone to provoke a blood clot and a healing response. Emory Sports Medicine is one of only 25 centers around the country studying cartilage transplantation.

Cartilage transplantation repairs damaged cartilage with replacement cartilage. We mix the donated cartilage with fibren glue (a common medium for biological repairs), form it into a patch of the appropriate size and shape, and insert it into the damaged area. Low and behold, it knits with the surrounding cartilage, stays in place, and forms new, healthy cartilage.

Unlike with many organ transplants, a cartilage transplant does not provoke a harmful immune response that could lead to rejection of the transplant. Cartilage is “avascular”: it doesn’t have any blood elements in it for the body to reject. This is why cartilage heals so slowly on its own, but it is also why we are able to transplant it without risk of rejection. It is what we call “immune-privileged tissue,” tissue that does not provoke an immune response.

Cartilage transplantation is still a new procedure. The study in which Emory Sports Medicine is participating will help us better determine the pros and cons of it in comparison to other approaches to cartilage repair. Will a repair made with actual replacement cartilage offer an expedited or improved recovery? We don’t yet know, but I can’t wait to find out.

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