Dr. Seth S. Greenky Blog

 

Advances in the art of replacing worn out joints occurs along many fronts…constantly.

Seth Greenky, MD

The materials we use are constantly being refined and perfected. Different metal alloys, ceramic, highly cross linked polyethylene, and porous metals that imitate bone are just a few examples of these materials.

The techniques for controlling pain continue to evolve. There are new mixtures of medications, premedication cocktails, spinal blocks containing specialized drugs, nerve blocks and many more pain modalities that are constantly being refined and improved.

Mobilization techniques have shortened a stay that 6 years ago was more than five days, to stays that now average a little over two days. Soon we will be pioneering joint replacements that will go home the same day as the surgery, making it essentially an outpatient procedure.

Recently the surgical technique for performing hip replacements has come under scrutiny. We are always looking for new ways of doing procedures that will allow faster recovery. There are a number of well documented techniques or approaches used to replace hips. The most common are: Posterior Approach, Lateral Approach, Anterolateral Approach, and the newer kid on the block, Anterior Approach.

The latest enthusiasm is for the Anterior Approach. The touted advantage is less muscle damage, faster recovery, no limitations regarding movements and less pain. Most surgeons in the US are not familiar with this approach. They have learned to perform it after completion of a formal course. In response to patient demand, new instrument sets, even new types of surgical tables have been introduced to support the procedure. The original description for a true direct anterior approach dates back to 1881. It has been used for different purposes throughout the years, but only recently for routine total hip replacements. It has gained in popularity because of the ongoing search for a less invasive approach.

Studies have been performed to see if this reputation of being “less invasive” is true. Most of the studies have been underpowered (low number of participants) and inconclusive. They do seem to show a faster rate of improvement at 6 weeks after surgery, but no different in function at 3-6 months after surgery. Pain, at least initially, is the same. The patients are not encumbered with any movement restrictions. The studies show there is a steep learning curve, even for the most experienced hip surgeons, taking up to 100 cases to reach true mastery.

Certain situations generally are seen as potential contraindications for this approach: obesity, previous surgery on the same joint, retained hardware from another operation, complex primary hip replacements, abnormal anatomy, and revision surgery are a few of these.

As with all types of surgery, the experience of both your surgeon and the hospital you select are critical to successful outcomes. Select a hospital that performs at least 1000 total joint replacements per year if possible. Select a surgeon that performs at least 100 joint replacement procedures per year. Many studies confirm that the complication rates are lower when the aforementioned criteria are met.

 

Injections to Treat Osteoarthritis

Seth Greenky, MD

The treatment of osteoarthritis is progressive in nature and begins with nonsurgical interventions such as changing activity levels, physical therapy, occupational therapy, heat/ice, pain medications such as ibuprofen or nonsteroidal anti-inflammatory drugs, and injections. Osteoarthritis is the most common form of arthritis. It develops when cartilage, the smooth protective covering of the bones in the joints, breaks down resulting in damage to the surface of the bones causing pain, inflammation, stiffness, and reduced activity. The goal for these types of treatments is to relieve pain, optimize activity level, and delay surgical intervention. There are two very different medications that are used for hip and knee injections. The onset, mechanism and duration of action, and effect vary depending on the exact medication used in the injection.

Steroid Injections

Steroid medications are synthetic drugs closely resembling the hormones that are naturally produced by the body in the adrenal glands. Steroids are effective in pain relief by diminishing the inflammation in the joint area and by reducing the activity of the immune system. Steroids are sometimes administered systemically (distributed throughout the entire body) by ingestion, intravenously, or intramuscularly. Steroids are also administered locally by drops into eyes and ears, by creams onto the skin, or by the direct injection into joints, bursae (the lubricating sacs between tendons and bones), or into soft tissue areas. Methylprednisolone is the most frequently used steroid medication for this type of injection.

Steroid injections help relieve symptoms in many, but not all, patients by reducing the inflammation in the joint. The decision to move forward with a steroid injection is made only after your doctor has individually assessed your condition and taken into consideration age, current level of physical activity, and other medications that are being taken.

Steroid injections should not be used:

  • If an infection is present in the joint or anywhere else in the body

Steroid injections may be administered after careful consideration in patients

  • who have a potential bleeding problem or are on anticoagulants since there is an increased risk for bleeding at the site

Before administering a steroid injection your physician may aspirate joint fluid for testing, especially if a diagnosis is uncertain. A local anesthetic is often administered just prior to the steroid injection or in conjunction with the steroid injection. One needle is inserted, but two syringes are given through the same needle. The immediate pain relief can be attributed to the action of the local anesthetic and then the actual steroid portion of the injection has a rapid onset usually within 24-48 hours. The pain relief typically lasts from 6 to 12 weeks and serves as an interim treatment until the acute symptoms from a flare up subside. The steroid injection often reduces the joint inflammation thereby preserving joint structure and function. No more than 3-4 injections per year in the same location, at intervals not closer than every 3-4 months, are typically administered because it increases the risk of weakening tissues and structures in the injected area. Studies have shown that there is little to no systemic effects from injecting steroids in this manner.

Steroid injections are an effective way to decrease pain and temporarily improve function, but it is important to recognize that they do not cure the disease. Activity modification may be necessary to prevent recurrence of pain after the steroid relief has dissipated. Rarely, side effects such as infection, allergic reaction, localized bleeding, tendon rupture, and skin discoloration might occur.

Viscosupplementation

An alternative to steroid injection for pain relief in patients with osteoarthritis is the use of viscosupplementation. During this procedure, a thick fluid comprised of an extremely large carbon molecule similar to Hyaluronic acid is injected into the joint (most frequently the knee). Hyaluronic acid is a natural substance found normally in the synovial (joint) fluid. Its dual purpose is to act as a lubricant to enable bones to move smoothly and efficiently and to function as a shock absorber for joints. Research studies have shown that people with osteoarthritis have a lower than normal concentration of Hyaluronic acid in their joints.

This injection is often not the first choice injection because Hyaluronic acid is more expensive than steroids but the cost is usually covered by insurance.

Hyaluronic acid may be used:

  • if symptoms aren’t improved by pain medications or nondrug treatments
  • if you are unable to take nonsteroidal anti-inflammatory drugs
  • if steroid shots aren’t effective or are contraindicated

Five different versions of Hyaluronic acid injections are available for use. Some types require only one injection, but others require up to five injections to be administered weekly depending on the product that is selected by your physician.

Hyaluronic acid does not have an immediate pain relief effect. Over the course of the series of injections you may experience less pain in your joint. Immediately following the injection a local reaction may occur which includes pain, warmth, and minor swelling. These symptoms, if they occur, are short-lived and can be relieved by the application of ice to the injection site. Rare complications include a localized allergic reaction, infection and bleeding.

This injection might generate effects that can last for several months. Just as with steroid injections, Hyaluronic acid has anti-inflammatory and pain relieving properties, while additionally lubricating the moving parts within the joint. The injection’s effects may last up to several months but as with steroid injections, the medication does not reverse the damage caused by advancing arthritis.

Summary

Steroid and Hyaluronic Acid injections can be helpful to those arthritis sufferers who have not responded to the basic nonsurgical treatment options, or for those looking for a bridge to delay the need for a surgical procedure. This intervention, as well as other options, should be discussed with your orthopedic surgeon.

Reference: American Academy of Orthopedic Surgeons

 

Boning up on Osteoporosis

Seth Greenky, MD

Necessary evils of all surgical subspecialties are important medical conditions that don’t require surgery but require other intervention. One such condition is osteoporosis, a problem responsible for contributing to more than 1.5 million fractures each year. Orthopedists are in the frontline in this battle so we unfortunately must deal with it.

A broken bone may be more than meets the eye. It might be an early warning sign that you have osteoporosis. Although osteoporosis is a fairly commonly used medical term in 2009, most people aren’t really aware of thefar-reaching impact of this major health problem and the risk that it poses.

Osteoporosis (also call porous bone) is a condition that causes a loss of bone mineral density (BMD) resulting in the body’s bone becoming sponge-like and porous (filled with holes). It gradually weakens the bones and makes them vulnerable to injury over time. Persons with low bone density have a higher risk for an initial fracture and then a laterre-fracture of the bones that are impacted by this disease.

Osteoporosis is a silent disease and people are often completely unaware that they are inflicted with this condition until experiencing a fall that normally would have had minor impact, results in a fractured wrist, hip, orcompression fracture of the spine.

A Compelling Argument for Action

Consider the impact to society. Osteoporosis contributes to more than 1.5 million fractures each year, including:

  • 300,000 hip fractures
  • 700,000 spine (vertebral) fractures
  • 250,000 wrist fractures
  • 300,000 fractures at other areas of the body

Often, the fracture dramatically impacts a person’s well-being and abilityto live and function independently:

  • The risk of a serious repeat fracture can more than double after experiencing the first fracture
  • One out of four people who experience an osteoporotic hip fracture will need long-term nursing home care
  • More than half the people experiencing osteoporotic hip fractures will be unable to walk without the use of an assistive device
  • People experiencing an osteoporotic hip fracture have a 24% increased risk of dying within one year following the fracture

Hip fractures heal slowly, cause significant physical pain, and result in long-lasting disability. Their impact is far reaching and extends toothers beyond the person experiencing the fracture. A broken bone does not always mean an individual has osteoporosis. It does mean, however, that bone density testing should be considered to determine if it is a possiblecontributing cause. Discuss this with your doctor.

According to the National Osteoporosis Foundation, more than 10 million Americans have osteoporosis and over 30 million have a bone density mass low enough that they are at risk for the disease.

The Many Faces of Osteoporosis

It may surprise you who should be concerned about developing osteoporosis. Although aging Caucasian women are well-recognized to be affected by the disease, more than 2 million American men have osteoporosis as well. The loss of bone knows no age boundaries and can also begin as young as the midtwenties.

Factors that put you at risk for developing osteoporosis include:

  • Aging
  • Caucasian race
  • Family history of osteoporosis
  • Small bone structure or being thinner than normal
  • Lack of weight-bearing exercise
  • Smoking cigarettes
  • Excessive alcohol intake
  • Reduced levels of estrogen after menopause
  • Long term use of certain drugs such as steroids
  • Low dietary intake of calcium or the reduced ability to absorb calcium and vitamin D

Diagnosis

Osteoporosis is usually diagnosed by your doctor by conducting a complete medical history and physical, x-rays, laboratory tests, and bone density testing. Bone density testing is an x-ray technique that compares your own bone density to the peak bone density of a person usually in the midtwenties of your same sex and ethnicity.

Prevention

Osteoporosis is preventable and treatable. Preventative measures should actually begin in childhood. Eating a well-balanced, calcium-rich diet and regular physical exercise are critical to ensuring healthy bones. Bone mass reaches its peak in the mid twenties and then levels off. After people reach their mid thirties, bone mass begins to decline. Adopting a life-long diet rich in calcium and vitamin D (milk, cheese, yogurt, soy, almonds, leafy green vegetables), engaging in regular weight-bearing exercise such as walking, hiking, jogging, and tennis, and avoiding habits that lead to calcium loss such as excessive alcohol consumption and cigarette smoking, can reduce bone density loss. Vitamin D in sufficient quantities supports the effective absorption of calcium. Calcium
supplements may also be an effective way to ensure an adequate daily intake of this important nutrient. Ask your doctor for the calcium supplementthat is right for you.

Treatment

It is impossible to replace bone that has been lost so treatment focuses on reducing the further loss of bone and preventing injuries. Although there is no cure for osteoporosis, there are many medications that are effective in slowing the loss of bone and increasing bone density. Discuss medication options with your doctor if you have a family history ofosteoporosis or have been diagnosed with it by bone density testing.

Conclusion

Osteoporosis is a major health problem affecting millions of Americans. Your doctor and you can effectively develop and implement a combination of measures to prevent the further loss of bone, establish effective exercise and nutritional therapies, explore medication treatment options, and adopt practices to minimize your risk of injury. Be sure to discuss theseoptions with your doctor at your next visit.

References:

  • American Academy of Orthopedic Surgeons
  • Centers for Disease Control and Prevention
  • National Osteoporosis Foundation

Lifewings: A commitment to safety

Seth Greenky, MD

The Orthopedic Team is eagerly anticipating the launch of the LifeWings Patient Safety Program at St. Joseph’s Hospital in early June. Through our organized service line efforts we have made tremendous progress in improving operational efficiencies and patient outcomes over the years but also recognize that continued and sustained improvement requires ongoingeffort and intervention.

Physicians, nurses, and other support team members will participate in intensive training sessions specifically designed for St. Joseph’s Hospital by LifeWings Partners. LifeWings is a team of physicians, nurses, pilots, and former astronauts that have adapted for healthcare the teamwork training framework used by commercial aviation. Through interactive exercises, experiential examples, evidence-based strategies, and tools and checklists we will learn how to avoid the mistakes that are occasionallymade by teams and improve the safety for our patients.

We recognize that the system and environment of care at St. Joseph’s can be purposely and methodically redesigned to achieve results even better than those produced now. We applaud the investment that St. Joseph’s Hospital has made to bring this program to us. It truly demonstrates the commitmentto creating and sustaining a culture of safety for our patients.

Granting the wish to walk

Seth Greenky, MD

Greetings from Nepal. I have embarked on our "pre-trip" to Nepal a few days early to spend some "adventure-time" with two of my sons. We will enjoy exploring and trekking for a week and will then meet up with Kim Murray and Mike O’Hara in Kathmandu to begin the exciting process ofplanning for our surgery visit in November.

Should you be wondering what a trekk in Nepal might involve, our approximate itinerary is as follows:

31 May’2011: Fly Pokhara to Jomsom [15-20 minutes] and trek to Kagbeni [approx 04 hours walk]: It will be a sunny and windy day and the temperature will be approx 20 – 28 degree Celsius. On the way to Kagbeni they have to cross Kali Gandaki River via wooden bridge and Lubra River. Enroute you will pass throughsmall village.

01 June’2011: Trek Kagbeni to Muktinath (3800m) – 03 hours: Usually the weather and climate will be the same as Kagbeni. On the way we will pass through small villages called Khing and Jarkot and reach to Muktinath for overnight stay.

02 June’2011: Trek back visit Lubra village and Jomsom – 4 hoursAfter breakfast we descent to Lubra river. We are high above the river again and must cross two bigger side-valleys on the way downstream. Eventually we come to some fenced-in fields and a garden with apple trees, near Lubra’s village school.

After Lubra, the trail leads to the Kali Gandaki and we have to leap across the river Panga a couple of times! At the confluence of the two rivers we join the caravan of tourists going to Jomsom The climate will be similarto Muktinath and in the afternoon it will be a windy day.

03 June’2011: Trek to Tukche village (2590m): 3 hoursThe climate will be similar to Muktinath. On the way we will pass small village called Syang and then to Marpha which is very famous for Apple wine and there is big agriculture farm and this area is very famous for apple and then to Tukche village.

04 June’2011: Trek to Gasa (1080m) 5-6 hours:Day will be warmer but possibility of rainfall. This day we have to cross Kali Gandaki river couple of times and we will reach Kalapani, from here we have to walk through pine forest and descent to Lete village and after crossing the river, level walk to through forest to Gasa village for overnight stay.

05 June’2011: Drive from Gasa by local jeep to Beni and to Pokhara: Today after breakfast we will drive from Gasa by local jeep to Beni via tatopani and from Beni we will have a private transfer from to Pokhara. Total driving hours will be approx 06 hours. From Gasa to Beni off road and from Beni to Pokhara is black topped.

Once back in Kathmandu we will tour all relevant portions of the hospital, spend time with a representative from the Ministry of Health, meet several of our prospective patients, and most importantly, assess theenvironment in which we will be performing surgery this fall.

Look forward to reading many exciting observations and stories upcoming blogs after we return. Stay tuned for photos as well.

Multimodal pain management during joint replacement surgery

Seth Greenky, MD

We recognize that pain is a major concern for a patient about to undergo hip or knee replacement surgery. Educating yourself about pain and effective ways to manage it before experiencing surgical pain can reduce your fear and assist you to manage your expectations and ultimately, yourpost-operative pain.

Orthopedic surgeons are continuously challenged to find a pain relief regime that reduces the amount of pain that a patient experiences while minimizing the side effects of narcotics and other analgesics. Inadequate pain control potentially delays physical therapy progress, hospital discharge, and the overall surgical recovery time. More and more research is emerging that supports the use of a Multimodal Pain Management Strategyas the most effective mechanism to control pain, promote mobility, andimprove functional outcomes after hip and knee replacement.

What is it?

Multimodal analgesia or balanced analgesia is the use of more than one method of managing or controlling pain. It involves administering multiple drug and treatment modalities utilizing more than a single route of administration across the entire surgical course or perioperative continuumincluding:

  • Preoperative period (before surgery)
  • Intra-operative (during surgery)
  • Post-operative (after surgery)

Post-operative pain is the result of a complex series of events and reactions within the body as the result of the trauma or assault caused by the surgical procedure. The response to pain is triggered by reactions occurring locally at the site of the surgery as well as centrally in the brain. Using a combination of methods and drugs to control pain at the surgical site as well as centrally in the nervous system achieves theoptimal pain control results.

Preoperative Phase of Care

Measures begin prior to the surgical incision. They reduce the need for opioid drugs after surgery and usually include a combination of one or moreof the following drugs:

NSAIDs

  • Nonsteroidal anti-inflammatory drugs that have analgesic, fever-reducing, and inflammation reducing properties

Cox-2 Inhibitors

  • A newer type of nonsteroidal anti-inflammatory drug that directly targets an enzyme responsible for inflammation and pain

Anti-neuropathics

  • A type of drug that is often used to treat seizures and neuropathic pain syndromes. Studies have found that these drugs can help reduce the pain signals that are sent to the brain and result in reduced post-operative pain and use of morphine

Intraoperative Phase of Care

Measures are implemented during the surgical procedure. They may include a combination of one or more of the following:

Spinal Analgesia/Spine Block (Regional Anesthesia)

  • Uses local anesthetics to blockade the central sensory and motor receptors for the time during the surgery as well as into the post-operative recovery phase of care
  • Also assists in reducing surgical blood loss and may diminish the incidence of post-operative nausea and vomiting as well

Peripheral Nerve Blocks

  • The injection of a local anesthetic onto or near nerves for the temporary control of pain
  • Performed either with a single injection or a continuous infusion through a catheter

Intraoperative Injections

  • Use of "cocktails" comprised of morphine, an anti-inflammatory, and a local anesthetic to block the inflammatory and pain pathways

Post-operative Phase of Care

Measures are implemented during the recovery period. They may include a combination of one or more of the following:

Intravenous Patient Controlled Analgesia (PCA)

  • Utilizes infusion pumps to deliver patient initiated small doses of opioids (morphine, hydromorphone, fentanyl)
  • Patients must be willing and able to actually participate in their care

Continuous Non-narcotic, Surgical Site Pain Relief Pump

  • A device that continuously pumps a local anesthetic through a catheter to the surgical site and surrounding area for 1-2 days after the surgery

Acetaminophen

  • Results in reduced opioid requirements

There is no single approach to multimodal pain management that has emerged as the best practice method. There are myriad variations to the approaches used by joint replacement surgeons and anesthesia providers but theelements are similar and they all focus on·

  • Getting ahead of pain (preventing it before it begins)
  • Reducing the use of narcotics
  • Reducing nausea and vomiting
  • Diminishing post-operative sleepiness
  • Promotion of early mobility (which also minimizes the risk of deep venous thrombosis-DVT)
  • Contributing to the overall improved surgical outcomes and early discharge from the hospital

If joint replacement surgery is in your near future, be inquisitive and ask your surgeon about his or her adoption of this approach to managing post-operative pain. Take charge of your health and be your own bestpatient advocate.

References:

Gandhi, K. & Viscusi, E., Multimodal Pain Management Techniques in Hip and Knee Arthroplasty. The Journal of New York School of RegionalAnesthesia, July, 2009.

Harlocker, T., Kopp, S., Pagnano, M., & Hebl, J., Analgesia for Total Hip and Knee Arthroplasty: A Multimodal Pathway Featuring Peripheral Nerve Block. Journal of the American Academy of Orthopedic Surgeons, March,2006.

Joshi, GP., Ogunnaike, BO., Consequences of Inadequate Postoperative Pain Relief and Chronic Persistent Postoperative Pain. AnesthesiologyClinics of North America, 2005.

Poruczni, M., Two Views on Multimodal Pain management. American Academy of Orthopedic Surgeons Now, July, 2010.

 

The Road to Orthopedics

I am frequently asked by patients, students, health care providers, and others, what it takes to become a surgeon, or more specifically an orthopedic surgeon. What is the genome and make up of an orthopedic surgeon? Although the path to becoming an orthopedic physician is similar for all, individual life experiences and environment significantly contribute to selecting a medical specialty.

The stage is usually set in high school. Excellent academic standards, a high motivational level, perseverance, and boundless energy serve as the fuel to begin the rigorous process that will consume the next 14-15 years of your life.

After high school the first stepping stone along the traditional path, commonly referred to as “premed”, is to obtain a Baccalaureate degree in Science at an accredited college or university. The curriculum is rigorous and challenging during these four critical years and includes coursework such as biology, chemistry (organic, inorganic, biochemistry), physics, genetics, and calculus. Simultaneous to that, a premed student is also involved in many extracurricular activities to ensure a well-rounded personal portfolio when applying to medical schools.

There is one additional challenge to conquer during the undergraduate phase of the process: the MCAT (Medical College Admission Test). This examination is a standardized multiple choice test designed to assess the candidate’s abilities in the areas of problem solving, critical thinking, and overall knowledge base of scientific principles. The goal of the undergraduate education years is simply to be a high performer in all areas including the academic GPA and testing scores while also striving to become a well rounded person with diverse interests. With these goals in mind, the next step in the process is to complete and submit the ever-important medical school application. Most often, prospective candidates apply to a large number of schools hoping to be asked to interview at a few.

Medical school, a four year program, is customarily divided into two segments. The first two years are dedicated to classroom course work including anatomy, physiology, pharmacokinetics, and pathology. The last two years of the program involve a variety of clinical experiences including observations in physician offices, hospital units, and other clinical settings. It is during this time that most medical students decide on a specialty. Certain medical specialties are more competitive than others with cardiothoracic, neurosurgery, and orthopedics being at the top of that list. This is a highly competitive phase in the process and the failure/dropout rate from medical school is quite high. The individual’s ability to perform is tested to the extreme. It isn’t unlike someone desiring to be a professional athlete. To be a professional football player a person may have the motivation and the drive, but not every athlete has the necessary skill set to make this dream a reality.

During the medical school years we also take the first two parts of the US Medical Licensing Exam that assesses our ability to apply knowledge, concepts, and principles as well as demonstrate competency in the basic patient care skills that are critical for safe and effective patient care.

The fourth year of medical school adds another dimension to the stresses and rigors of the road: applications and interviews for residency programs in our desired specialty. Examples of surgical specialties include orthopedics, general surgery, cardiothoracic surgery, urology, ENT, and other nonsurgical specialties include areas such as family medicine, pediatrics, psychiatry, OB/GYN, radiology, and anesthesia. Assuming that medical school has been a success, the first two portions of the medical licensing exam have been passed, and medical school interviews have gone well, we then experience what is known as “Match Day”. This occurs in March each year and involves a computer matching us with a residency program, hopefully at a program high on our priority list.

A residency program for orthopedics and surgical specialties is typically 5 years in length, while medical residencies are usually 3-4 years. During the first year of residency a temporary medical license is issued and you are sometimes referred to as an intern. This year involves spending many hours in the hospital under close supervision and culminates with completion of the third part of the licensing exam. This portion of the exam, a two day session, is by far the most rigorous and challenging. Day one of the examination is comprised of 8 hours of multiple choice test questions with minimal breaks. Day two consists of a session of continued multiple choice test questions followed by a session of case simulations. The process is grueling and stressful.

After successfully completing all three segments of the medical licensing examination we are awarded a restricted license to practice as a physician. The unrestricted license to practice in the capacity as an attending physician without limitations is only granted after completion of, and graduation from, the full residency program. Immediately following graduation yet another exam awaits us-the American Board of Orthopedic Surgery test which must be passed in order to become what is considered “board eligible”.

During our residency years we do what the process has prepared us to do for the past eight years-care for patients with orthopedic specific conditions under the supervision of attending surgeons. As the residency years progress, the level of autonomy we are granted escalates. Another milestone happens during the residency years-this is the first time you are paid a salary, albeit small.

After graduation from the residency program we can either enter the arena of practicing orthopedic surgeons, or perform an additional year of subspecialty training known as a fellowship. Fellowship programs are structured to provide an intensive experience in an orthopedic subspecialty such as total joint, spine, sports medicine, oncology, hand, upper extremity, foot/ankle, or pediatrics. This is a highly desirable step to further hone our knowledge base and skills, but it also delays becoming a member of the orthopedic workforce by another year.

After completing a fellowship, we are ready to begin our own practice. We must be licensed by the state in which we choose to set up our practice, and must also apply for privileges at the hospital(s) in which we will be working. It is at this point, after 14 years of preparation, that we are now considered independent in our practice. Despite this, the testing is still not complete. After 2 years of being in independent practice we then must take Part 2 of the American Board of Orthopedic Surgery exam. This consists of an oral examination administered by several individuals questioning us about actual surgery cases (blinded) that we performed the previous year. Successful completion of this portion of the exam now entitles us to refer to ourselves as “Board Certified”.

Although the formal education process is finished, the learning process is life-long. Ongoing clinical outcome studies, new drugs, and technology advancements require that we remain ever vigilant and attentive to new developments in evidence based practice so we can provide our patients the highest standard of care. We do this both voluntarily as a commitment to our profession and patients, as well as a regulatory requirement of the state requirements to maintain our licensure. Continuing education credits for physicians are called CME’s (continuing medical education) and the exact requirement varies state by state. The American Board of Orthopedic Surgery also sets a standard for CME requirements and requires each of us to sit for a recertification exam every 10 years to demonstrate that we continue to be competent to practice orthopedics.

This profiles the most traditional path to orthopedic surgery, however not the sole route. For some, my brother Brett and I included, the undergraduate years are not spent in the traditional premedicine track. A wrestling injury experienced by Brett during our undergraduate years at North Western was the catalyst sparking our interest both in medicine in general, and in orthopedics more specifically. It was at that point that we initiated the process that led us to medical school. Even more frequently today, medical school students are often from diverse backgrounds that steered them later in life to medicine rather than following the traditional pathway that originates in high school. Two of my sons are examples of the more nontraditional entry into medicine having completed undergraduate programs outside the science domain.

Regardless of the path that led to the medical profession, the road to orthopedics is filled with years upon years of education, countless hours in the clinical setting, endless studying, and myriad examinations intended to result in survival of only the fittest and best suited for the profession. Reflecting back on the more than twenty years of my orthopedic practice, in addition to the fourteen years I spent in education, residency, studying, and examinations, I am glad that I chose the road to orthopedics because the harvest I have reaped is far greater than that which I have sewn.