Dr. Brett B. Greenky Blog

 

Operation Walk Syracuse Extends Gratitude to Franciscan

Brett Greenky, M.D.

Operation Walk Syracuse would like to extend our heartfelt appreciation to Franciscan Companies for their tremendous support to Operation Walk Syracuse. Thanks to their donation our Nepalese patients will have the use of reacher/grabbers, sock aides, commodes, raisted toilet seats, wheelchairs, oximeters, and glucose monitors during our November visit. It is through the generosity of groups like Franciscan that we are able to provide this life-altering procedure for people around the world with limited access to care.

Franciscan Companies is an affiliate of St. Joseph’s Hospital Health Center. Through a variety of companies and partnerships, Franciscan Companies extends the reach of the St. Joseph’s network throughout the Central New York community. From home health care services to durable medical equipment, from infusion services to medication dispensing machines, Franciscan ensures that patients discharged from St. Joseph’s Hospital-as well as other hospitals in the area-receive the continued care, services and products they need for improved health and comfort.

Operation Walk Syracuse: Preparing For Panama

02/27/2013

Brett Greenky, M.D.

Operation Walk Syracuse is a group of orthopedic specialists (surgeons, medical doctors, nurses, anesthesiologists, and physical therapists) who travel to countries that lack ample access to desperately needed hip and knee replacement surgeries. The surgeries are performed at no cost and patients receive the same state of the art services that our patients receive here at home. This post highlights the "pre-trip" the group made to Panama recently, preparing for their longer trip in November 2012. Last year the group traveled to Nepal , performing more than 75 hip and knee replacements.

Thousands of miles closer, a fraction of the travel time, one hour difference in time, and the luxury of clean, running water, ample electricity, and sound building structures-this is Panama City, Panama . We joked casually as we were chauffeured from the airport in Panama City to the modest hotel that would serve as home base during our pre-trip visit to St. Tomas Hospital. We were preparing for our upcoming annual Operation Walk trip in November, 2012. We (Dr. Brett Greenky, Mike O’Hara, and I) discussed the stark contrast of Panama City in comparison to Kathmandu, Nepal our 2011 Operation Walk Syracuse destination. We speculated about the hospital, the working conditions, the medical staff, equipment challenges, and our potential patients. A literal world of difference from the far away and exotic land of Nepal , this mission should be a virtual walk in the park from a comparative standpoint.

Our small "scouting" team was warmly greeted by the Panamanians and hospital staff, and eagerly embraced and integrated into the Operation Walk Team visiting Panama City for their annual trip. Operation Walk Denver, a long time established Operation Walk group, had graciously permitted us to coordinate our "pretrip" visit with their scheduled mission trip to enable us to draw from their vast experience as an established team, as well as to permit them to show us the lay of the land at St. Tomas Hospital.

True to our beliefs, the differences were vast-a modern city with a fairly well equipped hospital rivaling many in the US in terms of the structure and facility features. Lacking, however, was the capacity to provide the people of Panama with life altering joint replacement surgery primarily due to the supply and demand. There simply aren’t enough joint replacement surgeons in Panama to meet the surgical needs of their people. It is for this very reason that Operation Walk teams are warmly embraced and welcomed into this country. The surgery missions are viewed by both government and hospital officials as a conduit for meeting the needs of their people; in essence, a salvation for them.

Our "perceived" differences between Kathmandu and Panama City rapidly dissipated as we filed into the patient screening clinic that had been assembled in anticipation of our arrival accompanying the Operation Walk Denver team. As we wound our way through the waiting room crowded with potential patients and their families, applause erupted and cheers echoed from the walls from the hundreds of people crowding the room. The American team offering the promise to relieve the pain and suffering for some, and restoring the ability to walk for others, had arrived.

The next six hours flew by in what seemed like mere minutes. Grateful patients and their families were ushered into screening rooms and evaluated by teams comprised of surgeons, medical doctors, anesthesiologists, and nurses. We encountered elderly people crippled from pain who had limbs misaligned by the long term effects of osteoarthritis. We met young people, eyes filled with hope for a better future, who had fused hips and/or knees with little or no mobility due to advanced rheumatoid arthritis that had been left untreated due to the lack of availability of disease modifying medications which are readily accessible in the US but not available in this country.

The potential patients were all impeccably dressed in Sunday best for their appointments with the Operation Walk team, wanting to demonstrate respect and admiration for the Americans who had come to offer them hope and relief. We quickly learned from the Denver team and from the Panama

physicians that their lifestyle reality is actually dramatically different from the way they presented to us. Many live in condition of complete squalor and poverty, but their pride and respect for Operation Walk inspires them to present themselves immaculately coiffed and wearing what might be their only untattered garment. Most of the patients were candidates for bilateral hip or knee replacements, and whenever medically feasible, procedures on both sides would be performed. For those patients only able to tolerate a single procedure, they were offered the hope of having the second surgery done when we, Operation Walk Syracuse, returns in November. The same held true for those patients who had medical conditions such as heart disease or diabetes that had to be brought under control prior to undergoing a surgical procedure. These patients were all considered to be in our "bullpen" and in the queue for surgery in November upon our return.

So, back to the differences-Nepal versus Panama City-the city, the hospital, the environment couldn’t not have been more in contrast, but the differences end there. Glance into the eyes of the people, old or young, patient or family member, and we were witness to the same basic need and hope for relief from suffering. It transcends several continents and many thousands of miles. Once again as we embark on this new journey to Panama City , we are forever humbled by the honor and privilege of caring for those less fortunate brothers and sisters in our world.

The Power of Teams

Brett Greenky, MD

Anyone who knows us well, knows our sentiment about "our team." Being branded a team does not in itself make a team, in fact, far from it. The word "team" is overused and in fact often misused. At worst, people can be brought together structurally and be nothing more than folks functioning independently without common goals or vision. Conversely, assemble people who share a common belief in their own ability to create and contribute to exceptional patient outcomes and there you find constituent parts that work as a unified whole. Take a close look at our team and you will quickly recognize how highly interdependent we all are to achieve the results that we do. Everyone wins on our team, most importantly the patient. The Total Joint Replacement Program at St. Joseph’s Hospital consists of clinical and nonclinical people from our office, the hospital, and homecare providers. All of us are critically important to the care that our patients receive and the outcomes that they achieve. The whole is greater than the sum of the parts.

Throughout the years scientists have researched why migratory birds such as geese fly in a V-shaped formation. Recently a team of scientists from France had the opportunity to study great white pelicans that had been trained to fly behind aircraft and boats in preparation for a feature film. The scientists found that the heart rates of these birds dramatically decreased when they were flying together and that they were able to glide for longer periods of time, thus reducing the energy they exerted during their journey. These findings suggest that flight formation evolved as a means to allow birds to reduce their energy expenditure. Birds flying in a V had lower heart rates and experienced less air resistance than birds flying solo. The bird in the lead position of a V formation will experience greater air resistance, will work harder, and fatigue more quickly than the other birds. The flight formation (or team process) then compensates for this. When the lead bird wearies, it falls out of the lead and allows another bird to take its place. This exchange takes only a second or two and is barely evident from the ground. The process of the lead bird changing out each time it becomes exhausted continues throughout the entire migratory journey, with each new bird offering strength along the way. This formation permits all the birds to benefit individually while they work harmoniously as a team.

Like those migratory birds, we all share a portion of ourselves with each other. Each of us is willing to pitch in and do whatever is needed. We share a sense of common goals, open communication, mutual trust, and individual accountability. It truly is a Herculean effort to accomplish what we do.

Thanks Team!

References:

"Bird Flight Explained," BBC News World Edition, December 16, 2002.

Unicompartmental Knee Replacement: Bone sparing alternative

Brett Greenky, MD

Alternative Names: Partial Knee Replacement, Unicondylar Knee Replacement, Unicompartmental Knee Replacement, Unicompartmental Knee Arthroplasty, Minimally Invasive Partial Knee Replacement.

More than 500,000 people in the United States undergo total knee replacement each year. Some of these patients and an additional gorup of other indivudals with knee arthritis might be candidates for partial knee replacement.

Knee Anatomy Three bones join together to form the knee joint

  • Thighbone (femur)
  • Shinbone (tibia)
  • Kneecap (patella)

The knee components are held together by muscles, ligaments, and soft tissue. The shock-absorbing material inside the joint that cushions during weight-bearing activities is called the cartilage.

The knee is comprised of three separate section:

  • The medial compartment (inside part of the knee)
  • The lateral compartment (outside part of the knee)
  • The patellofemoral compartment (front part of knee between the kneecap and thigh bone)

Knee Arthritis

Osteoarthritis, or wear-and-tear arthritis, often results in symptoms such as stiffness, pain, and/or a sensation that the knee has "locked" during walking or other activity. The cartilage in the knee degenerates over time until the surfaces are rubbing directly with each other without any cushioning (bone on bone).

Rheumatoid arthritis is an inflammatory process resulting in damage to the surface of the knee joint. Partial knee replacement (PKR) is not indicated in rheumatoid arthritis.

Unicompartmental arthritis is wear and tear disease that affects only one of the three compartments of the joint instead of the entire knee.

Partial Versus Total Knee Replacement

Knee replacement surgery is intended to relieve knee pain and to imporve the function and motion of the knee.

A total knee replacement (TKR) involves the complete repalcement of all three components in the knee. Unicompartmental, or partial knee replacement, allows the surgeon to resurface (or replace) only the damaged compartment of the knee while preserving the health y bone in the other two compartments.

Patients suffering from osteoarthritis that is isolated to only one part/compartment of the knee might be candidates for partial knee replacement. The healthy parts remain untouched during the surgery. Patients also have the opportunity to undergo a standard total knee replacement in the future if the arthritis progresses and additional surgery is needed.

Historical Perspective

Partial knee replecement actually predated Total Knee Replacement. In the 1960′s when the idea of resurfacing an arthritic knee joint was first successfully accomplished, it was with a partial design. It was only after the intial success of these designs that surgeon developers linked together two partials to make the first "Total Knee"-the Duopatellar. Over the years "total" knee designs have become more and more anatomic following the lead of nature. At the same time partial knee replacement was overshadowed by the success of the "total" design despite the fact that it works so well in certain circumstances. The continued improvement in material science has increased the longevity of both partial and total knee components. Partial knee replacement, when applied to the correct patient, can have superior fuctional results when compared to"total" knee replacement. The operative procedure remains more technically demanding for the surgeon, and is therefore usually provided only by orthopedic surgeons who are Joint Replacement Specialists.

The Procedure

Although the surgeon is able to predict with a high degree of accuracyby review of the x-ray if a patient is a candidate for PKR, the first step in the actual surgical procedure is to examine the three compartments of the knee directly to verify that cartilage damage is present in only one compartment of the knee. If the damage is more significant than was visible on the preoperative x-ray, the surgeon will perform a total knee replacement instead. He or she will discuss this possibility during the preoperative visit.

The term minimally invasive is often thought to relate to incision size. In the hands of a skilled surgeon, the incision size is approximately half the size of the incision made during total knee replacement. In terms of a partial knee replacement, the descripion of minimally invasive also correlates most closely to:

  • Preservation of two of the three compartments in the knee joint
  • Preservation of the stabilizing ligaments of the knee
  • Anterior cruciate ligament (ACL)
  • Posterior cruciate ligament (PCL)

During total knee replacement surgery these ligaments are usually cut or loosened. Keeping these intact helps retain a more normal sensation of movement and range of motion.

If the intraoperative examination supports partially resurfacing the knee:

  • The damaged bone is removed and replaced with implants (prostheses) made of plastic and metal
  • The ends of the thigh and shin bones are cut and reshaped
  • The metal implants are secured in place with a fixative substance called bone cement
  • A plastic insert is placed between the two metal components to enable the surfaces to freely glide

Advantages of PKR

  • Quicker recovery and return to normal activities of daily living
  • Smaller incision
  • No disruption of the knee cap
  • Less pain
  • Improved range of motion
  • Little to no blood loss
  • Reports of a more natural feel in the knee

Disadvantages of PKR

  • Potential for additional surgery in the future (if other compartments become damaged by osteoarthritis)

As possible with any surgical procedure, complications can rarely develop:

  • Blood clots
  • Infection
  • Nerve injury
  • Persistent pain
  • Implant failure

Activity

Most patients can resume normal activities after partial knee replacement when they have regained adequate strength and flexibility. Most exercise and activity are acceptable after surgery including walking, swimming, biking, gardening. Activities that result in repetitive joint trauma such as running, jumping, or twisting should be avoided.

Conclusion

Partial knee replacement can achieve excellent results when performed on the appropriate population of patients. This procedure may be an option for patients who are experiencing significant lifestyle limitations as the result of osteoarthritis isolated to one part of the knee.

If you believe that you may be a candidate for PKR talk to your doctor to determine what treatment is best for you. Since this procedure is technically more challenging and surgeon experience is a key driver of positive surgical outcomes, don’t be hesitant to discuss with your surgeon his or her experience with this procedure.

References

AAOS:

Berger RA, Meneghini RM, Jacobs JJ, et al. Results of unicompartmental knee arthroplasty at a minimum of ten years of follow-up. Journal Bone Joint Surgery Am. 2005; 87(5): 999-1006.

Smith & Nephew: www.RediscoverYourGo.com

Shoulder Arthritis

March 1, 2013

By Brett Greenky, M.D.

The shoulder joint is really made up of two Joints: The AC Joint and the Glenohumeral Joint. The AC joint is so named because the Acromion and the Clavicle touch together here. The Acromion is part of the shoulder blade. The AC joint can and does become arthritic. Spurs develop underneath the AC joint and these spurs can agitate the tendons of the rotator cuff. The rotator cuff tendons rub back and forth underneath the AC joint when the shoulder moves. The arthritic spurs of the AC joint can impinge on the rotator cuff tendon during shoulder motion. The resultant rotator cuff tendonitis is the most common cause of shoulder pain in adults over 40.

The Glenohumeral Joint (GHJ) is the main "ball and socket" part of the Shoulder. Arthritis of the ball and socket (GHJ) part of the shoulder is a less common affliction than AC joint arthritis. Many patients with mild to moderate degrees of (GHJ) arthritis can be treated with medications, activity modification and physical therapy or home based exercises. The purpose of these exercises is to that tone the rotator cuff muscles. When toned these muscles can help reduce the amount of rubbing in the GHJ. It is when the GHJ arthritis progresses to the severe stage that these techniques tend to no longer be adequate and total shoulder replacement (TSR) surgery is considered. Since patients do not need to walk on the shoulder joint, severely symptomatic shoulder arthritis comes late in the disease progression. As a result, most patients who seek treatment for severely symptomatic shoulder arthritis are already at the stage when TSR is the only treatment to afford dramatic relief.

Total Shoulder Replacement has a high success rate in reducing or eliminating shoulder arthritis pain. In general the operation is easier to navigate for the patient when compared to Total Hip or Total Knee replacement surgery since the Shoulder is a non-weight bearing joint. The operation is however requires a one to two day hospital stay and some postoperative physical therapy. A return to near normal function requires a well functioning rotator cuff. Much of the post operative treatment is directed to the strengthening of the rotator cuff muscles which often atrophy during the period of worsening arthritis. Since a functioning and intact rotator cuff is essential for traditional TSR surgery to be successful, the joint replacement specialist may need to do additional preoperative tests (MRI scan) to check the patient’s rotator cuff condition.

A special version of TSR is available for the patient with shoulder joint arthritis who does NOT have a functioning rotator cuff. This operation is called Reverse Shoulder Replacement. The operation reverses the polarity of the ball and socket of the shoulder thus explaining the name. This novel technique allows for pain reduction in the rotator cuff deficient patient but it does not restore the function of the rotator cuff itself. Patients without an intact rotator cuff are usually unable to elevate their arm much above the waist.

What Factors Affect the Result of my Knee or Hip Replacement

Brett Greenky, MD

Experience, Experience, Experience

Increasingly patients are accessing health care services to increase mobility, functionality, and pain-free lifestyle choices through joint replacement services. This year more than 560,000 knee replacements and over 400,000 hip replacements will be performed in the United States alone.

As our population ages, becomes more active and in some cases heavier, the need for joint replacement surgery is expected to increase over 300% in the next decade! Where should you go to get fixed? Data is available to help you make an informed decision. Consider these facts:

10 years ago, 60% of knee replacements were performed by surgeons who did less than 30 cases per year and in institutions that performed less than 100 cases per year. Currently there is a strong trend towards specialization in the delivery of hip and knee replacement services. Select hospitals that perform more than a 1000 cases per year are emerging. These institutions and the surgeons who work there have dramatically better results and lower complication rates when compared to the nonspecialized hospitals and surgeons. Studies over and over have shown lower pneumonia, urinary tract infection, deep infection, heart attacks, and blood clot rates after joint replacement surgery performed in these institutions. They all show the same thing: experience breeds excellence. The more experience, the bigger the gap in performance over the low volume centers. See for yourself:

  1. Journal of Bone and Joint Surgery (JBJS) 2004.95-99% confidence levels are exhibited; high volumes equal lower risks and better results.
  2. JBJS 2004. At the Brigham Hospital in Boston, surgeons doing less than 25 cases per year did 11% of the knee replacements but had problems at a rate twice as high as surgeons who do more than 100 cases per year.
  3. JBJS 2004. 81,000 Medicare patients were reviewed and results were superior in cases performed by surgeons with volumes above 50/ year compared with those done by surgeons with less than 12/ year.
  4. JBJS 2006. High volume surgeons superior results seem to benefit all patients, but especially those with co-morbidities (that means lots of other medical issues that could complicate an otherwise routine procedure).
  5. JBJS 2010. High volume surgeons and institutions provided care with lower rates of readmission, shorter lengths of stay in the hospital, more common discharge to home versus a rehab center, and lower risks of bleeding, infection, blood clots and pneumonia.
  6. The Proceedings of the Knee Society

2010. High surgical volumes increase the likelihood of positive patient outcomes. Higher volumes equal superior results—-Period. It is becoming clearer that super high volumes are even better than high volumes. Major joint replacement centers are emerging in many of America’s major cities. Hospitals that perform more than 1000 joint replacements per year are now available. These centers have established treatment protocols which streamline care and give reliable and reproducible results. There is little doubt that these centers and the corresponding surgeon staff will have the most experience in providing surgery services and exceptional patient outcomes.

We are fortunate in our community to have one of these centers: St Joseph’s Hospital Health Center. St. Joe’s performed nearly 1400 joint replacement surgeries in 2010, the most of any hospital in Central New York. Indeed, data from 2004-2005 suggests 46% of ALL of Central New York joint replacement operations are performed at St Joe’s! The team at SJH, headed by Drs. Seth and Brett Greenky is proud of our elite program and is dedicated to not only maintain an outstanding level of care, but to seek continuous improvement.