rthopaedics · pdf filelic. the magazine will introduce the ... a specific patient-tailored...

Volume 6 • Issue 1

TheFuTureIS Now

rthopaedics:A Tidewater Update

LIVE YOUR LIFE WITHOUT LIMITS

Why Choose Careplex Orthopaedic Ambulatory

Surgery Center?

3000 Coliseum Drive | Hampton, VA 23666757-736-4100 | careplexortho.com

Exclusively served by

Dr. Loel Payne

Dr. Nicholas Sablan

Dr. Paul Maloof

Dr. Colin Kingston

Dr. Jonathan Mason

Dr. Michael Higgins

Dr. Robert Campolattaro

Dr. Nicolas Smerlis

W hen having surgery the facility you choose is as important as the surgeon performing your surgery.

COASC is the Peninsula’s only dedicated orthopaedic Ambulatory Surgery Center which provides an excellent experience for both the patient and the surgeon for a variety of reasons. Our surgeons are fellowship trained which means they have received an additional year of specialty training in their specific field of orthopaedic surgery. All of our operating room staff have a minimum of two years experience working in orthopaedics so our surgeons have surgical technologists and nurses that are familiar with the procedures, instrumentation and implants. We have a near zero infection rate because all we do are orthopaedic cases and we do not operate on patients with an active infection. We work with a team of anesthesiologists who perform regional blocks for most cases. This means that only moderate sedation, not general anesthesia, is required and the block helps with pain control post operatively. We have our billing office in house so if you have questions regarding your bill, payments or insurance coverage you speak to someone at the facility. COASC is located with easy access on the Sentara CarePlex Hospital campus in Hampton, Virginia.

Technology on the Move

Joint Replacements Past, Present, and Future

Shoulder Surgery an Outpatient Procedure?

Manual Physical Therapy Uses in Orthopaedic Practice

From Our Patients

Carpal Tunnel Syndrome Symptoms, Diagnosis, and Treatment

Physician Extenders Improve Patient Access and Care

What is a “Certification of Added Qualification” in Orthopaedic Surgery?

The Challenge of Treating Fingertip Injuries

Physicians & Medical Staff

An Awesome Team of Specialists and Staff

4.

6.

10.

12.

14.

16.

18.

20.

22.

24.

26.

tidewaterortho.com • 3

WelcomeI am proud to welcome you to the Spring 2015 edition of

Orthopaedics—A Tidewater Update.

Never be the last to try something new – or the first. This axiom has been handed down to young surgeons for centuries. It stands in support of the central bioethical principle known as non-maleficence, a concept born in Hippocratic times as primum non nocere (“first, do no harm”). Alive and well today, it reminds us to remain ever vigilant of the full impact of our actions. Perhaps nowhere in modern medicine might we benefit more from this principle than our embrace of emerging medical technology.

Fueled by economy, industry and advertisement, the pace of medical technology development continues to accelerate. Although certainly an overall boon to our profession, the challenge to incorporate medical technology into responsible practice has become increasingly complex. We struggle to balance patient expectations with proven standards of care. The introductory aphorism implores us to temper ceaseless innovation with meticulous contemplation.

The progressive evolution of orthopaedics into distinct areas of subspecialty care has occurred (in part) in deference to this conflict, and remains a universally recognized powerful weapon in this battle. Through such subspecialty focus, surgeons develop the intimate experience in their respective field to remain progressive yet responsible stewards of medical technology.

Although the oldest orthopaedic group on the Peninsula, we remain the only practice dedicated to the contemporary model of subspecialty care. Through this commitment, we can offer the most advanced medical technology with the knowledge and technical skill necessary for its implementation to the benefit of our patients. We are proud to remain dedicated to their well-being, as well as to the “cutting edge”.

Warm Regards,

Robert M. Campolattaro, MDPresident, Tidewater Orthopaedics

Hampton Office901 Enterprise Parkway, Suite 900

Hampton, VA 23666

Williamsburg Office5208 Monticello Avenue, Suite 180

Williamsburg, VA 23188

Main Number(757) 827-2480

www.tidewaterortho.com

Our Mission:To provide the best patient experience through the highest quality of specialty orthopaedic care - blending sound medical ethics, technical excellence, integration of team members, and a commitment to leadership.

Contributing Writers:Michael E. Higgins, MD

Lindsay Gray, DPTColin Kingston, MD

Nicholas K. Sablan, MDNicholas A. Smerlis, MD

Orthopaedics - A Tidewater Update is an educational and informational resource for physicians and the pub-lic. The magazine will introduce the physicians, their staff and facilities. In addition, it will provide updates on new achievements in orthopaedics, as well as articles on orthopaedic-related injuries and treatments.

Inside This Issue

Orthopaedics: A Tidewater Update is designed and published by Custom Medical Design Group. To advertise in an upcoming issue please contact us at: 800.246.1637 or CustomMedicalDesignGroup.com. This publication may not be reproduced in part or whole without the express written consent of Custom Medical Design Group.Medical

TECHNOLOGYOn the Move

ADVANCES in technology continue to improve our lives. Examples are everywhere you look; from cell phones with Internet connectivity to cars that are equipped with turn-by-turn navigation and

back-up cameras. Technology also continues to benefit the field of medicine. Robotic-assisted knee replacement is the latest technological advance in joint replacement surgery, and it is taking these procedures to the next level of precision and reproducibility.

In February 2015, the Orthopaedic Hospital at Sentara CarePlex purchased the first Bluebelt Navio robot in the state of Virginia. This is an image-free system (no CT or MRI required) that combines robotic assistance with the established benefits of computer navigation. The Navio system represents a revolutionary step forward in the way orthopedic surgeons perform partial knee replacement.

For the past two decades, advances in joint replacement have been moving toward robotics. About ten years ago, software was developed that allowed surgeons to create a model of the lower extremity and knee on a computer in the operating room. This allows the surgeon to choose the proper size and fit the implant exactly as desired on the computer before any bone is removed. Robotics adds a precision and consistency to the procedure that the human hand alone cannot achieve.

The process starts with planning a procedure that takes into consideration the unique anatomy of the patient. Rather than a time-consuming and radiation-intensive CT scan, the Navio approach employs a simple x-ray before surgery. The surgeon uses advanced planning software to tailor the surgery to the patient’s anatomy, align the implant, and balance the knee. Using state-of-the-art robotics-assisted technology, the system works with the surgeon’s skilled hands to achieve precise positioning of the knee implant for consistently accurate results. The Navio Robot System uses a smart tool that prevents the surgeon from unnecessarily

Robotic assistance is the future of joint replacement and joint preservation surgery.”

4 • Orthopaedics: A Tidewater Update

By Michael E. Higgins, MD

removing bone. A specific patient-tailored plan is developed for each procedure.

The Navio Robotic System allows for minimal removal of bone when performing partial knee replacements. The precision and control of the robot also facilitates a less invasive surgery with the potential for cutting less (or even none) of the quadriceps tendon. This should allow patients a speedier recovery with less postoperative pain. That, in turn, can translate into less time in the hospital, less time using a walker or cane, and less time in physical therapy. Along with these benefits in the short term, the reproducible accuracy of implant placement achieved with the robot facilitates maximum longevity of the new knee.

The Navio robot is currently used for partial knee replacement, which is believed to be an option for 30 percent of patients who require knee replacement. Currently, however, less than 10 percent of knee replacements are partial. Hopefully, that statistic will change in the future, since partial knee replacement offers many advantages over total knee replacement. For instance:

Partial knee replacement patients have been found to be nearly three times more likely to be satisfied with their new knee compared with those who have total knee replacement.

Partial knee replacement involves less surgery than a total knee replacement; only the diseased portion of the knee is resurfaced, which allows for less pain and stiffness afterwards.

With partial knee replacement, two thirds of the knee is preserved along with the cruciate ligaments, resulting in more natural knee motion and a knee that feels more similar to the original.

Robotic assistance is now being used in over 15 percent of partial knee replacements in the United States. These numbers are expected to increase worldwide as data continues to emerge showing improved alignment and soft tissue balance with this technology. The goal is to bring the benefits of partial knee replacement to all patients who are candidates for the procedure.

Robotic assistance is the future of joint replacement and joint preservation surgery. Since their inception, these procedures have been improved and refined, and advancements will continue. Tidewater Orthopaedics is proud to offer this state-of-the-art technology right here in Hampton Roads.

©2015 DJO, LLC

Suggested motion-based product protocols are intended to help physicians administer efficient and effective treatments to provide consistent outcomes that increase patient satisfaction and reduce overall healthcare related costs.

Learn more: DJOGlobal.com/Motion-Is-Medicine

Optimal strength in key muscles is crucial to your ability to stay active.

+

Michael E. Higgins, MD, FAAOS, is a fellowship-trained hip and knee replacement specialist. He did his undergraduate studies at the State University of New York at Geneseo and went on to medical school at Upstate Medical University at Syracuse. Dr. Higgins did his orthopaedic residency at the University of Buffalo and did an additional year of specialty training focused on complex hip and knee replacement at the Roanoke Orthopaedic Center. He joined Tidewater Orthopaedics in 2006.


JOINT REPLACEMENTSPast, Present, and Future

MY interest in becoming an orthopaedic surgeon stems from the first case I observed as a medical student in 1989. I

had just completed my general surgery rotation, where “handling the soft tissue, such as skin” meant using finesse with very fine instruments. Dr. Michael Debakey was probably one of the most famous cardiothoracic surgeons visiting my school from Houston, Texas, and I was given the daunting task of presenting a case to him on grand rounds. The presentation went well, but I realized that general surgery was not for me.

Then I witnessed my first total knee replace-ment (TKR). Saws, hammers, drills, metal and plastic instrumentation—the whole debauchery more closely resembled a wood shop than the “finesse” surgery I had just observed. I followed the patient for two months, a retired CMSgt in the USAF, and he thanked me for giving him his ability to walk on the beach again with his grandchildren. At that point, the epiphany occurred and I knew that I wanted to become an orthopaedic surgeon!

In the 28 years since my first year of medical school, I have seen a tremendous change in total knee replacements. This article attempts to con-sider a brief history of the knee replacement.

The word arthroplasty is taken from arthro (meaning “joint”) and plasty (meaning “to change the surface of ”). Total knee arthroplasty replaces only the ends of the bone in the joint with metal, and cartilage is replaced by plastic. Often, we use the term “total knee replacement” in place of arthroplasty, since it is easier to say and to remember. However, a total knee replacement does not replace one’s muscles,

By Colin Kingston, MD


tendons, and all of the ligaments and bones. The result is not a “bionic” or robotic knee. But like most things in medicine, it is easier to say total knee replacement, and I will use this term interchangeably with arthroplasty.

The 1850’s is often cited as the time when attempts were made by surgeons to treat severe arthritis in the knee. They would take soft tissue (fat, skin, etc.) and interpose it within the joint surface or resect bone from the distal femur (thigh bone) and from the proximal tibia (shin bone). It did not work, nor did it relieve pain. In 1891, in Berlin, Germany, Dr. Thermestocles Gluck made a joint replacement for the knee out of ivory and fixed it to the bone with cement made of colophony, pumice, and plaster of Paris. It had short-lived results, high infection rate, and was not widely accepted. Most surgeons went back to using soft tissue interposition techniques, up until the 1950’s.

Dr. John Charnley from England is touted as the father of modern arthroplasty. In the 1950’s, he designed a prosthesis for hip replacement that had low friction and altered hip biomechanics. He changed the operating room environment. Dr. Charnley excluded people that were very active and anyone who weighed more than 200 pounds. He was recognized for his longlasting and reproducible results in the 1970’s. The modern era of total joint replacement had begun, and total knee replacements were about 10 years behind total hip replacements in the mass development and utilization.

In the 1950’s and 1960’s, knee designs came in two types. A hinged knee replacement was much like a hinge on a door and directly connected the thigh bone to the shin bone components. (See figure 1.)

The other design—which was more modern—was a condylar knee, in which the bearing surface from the femur was not attached to the bearing surface of the tibia. (See figure 2.)

There was still a high complica-tion rate of infection and prosthetic loosening. Therefore, this was still considered an experimental procedure to be done only at major institutions in large cities.

In the early 1970’s, the condylar knee design became more developed and had two designs—one that spared the cruciate ligaments (two ligaments in the center of the knee that stabilize rotation and front-to-back translation, ACL and PCL) and one that removes the cruciate ligaments, called a posterior stabilized or sacrificing prosthesis.

In 1974, replacing the undersurface of the patella (knee cap) became the standard in the United States. Also, components became

more modular, and noncemented components were developed that rely on roughened metal surfaces for the bone to grow into. Instruments became more universal.

In the late 1980’s, more orthopaedic surgeons were being trained in the subspecialty of total joint replacement. Patients were offered the opportunity to donate their own blood three to four weeks in advance, as the transfusion rate approached 40 percent. Patients often were admitted two to three days prior to the procedure to be cleared for the surgical intervention. The operation would take between two and three hours and the patient would spend up to 10 days in the hospital after surgery. Most patients would not be up and ambulating until two to three days after the procedure. Epidural anesthesia was considered a novel approach to help patients get through those first two or three days of severe pain. Drains were used and removed on the second or third day after surgery.

In the 1990’s, the plastic tibial bearing became mobile in theory to allow for a more natural rotation of the knee. (See figure 3.)

Total knee replacements were being done more commonly in community hospitals. Subtle changes in component designs were made to facilitate a more natural motion and to try to improve kneecap tracking. New surfaces and metal alloys were developed in an attempt to improve wear and function for the more active patients. Patients typically were admitted the day before surgery, had an outpatient medical clearance, and typically spent five to seven days in the hospital. Early motion was now being emphasized, and continuous progressive machines (CPM’s) become more commonplace. (See figure 4.)

In 2001, 266,000 total knee replacements were performed in the United States. From 2000 to the present, navigation-guided surgery, enhanced kinematics, wear-resistant bearing surfaces with better fixation, and robotic surgery have been developed to increase the longevity of the implants, expand indications of the surgery to include active patients, and improve operating room efficiency (and ultimately patient outcomes).

In 2011, 718,000 total knee replacements were performed in the United States (4.6 percent of all operations in U.S.) with the expectation that 3.4 million total knee replacements to be done annually by 2030. The need to improve efficiency in the operating room will be confounded as the actual number of orthopaedic surgeons is projected to decrease by 10-25 percent within the next decade. Currently, 25 percent of all orthopaedic surgeons are in their retirement age range.

Total knee replacement will remain a vital part of our health care

Figure 1: Hinge Knee prosthesis


Figure 2

Figure 3 Figure 4

delivery system, despite changes that place emphasis on value and cost over volume. The calculated adjusted quality years of life (or CAQY) is a statistical analysis that measures the societal impact a procedure may have on improving the quality of one’s life, taking into account the cost of the procedure. In other words, if there is only so much money to pay for elective operations, where is the government/society going to get the most bang for their buck? Currently, cataract surgery has the highest CAQY, followed by total knee replacement. Total knee replacement has a 15 times greater CAQY than coronary artery bypass surgery.

In 2006, I started using comput-er navigation to better align the components within the knee. This was done not only to improve the outcome and function, but hopefully to increase the longev-ity of the implant. The purpose was also to prevent placing com-ponents in a malaligned position. (See Figure 5.)

From 1996 to 2006, my results in total knee replacements were 85 percent good-to-excellent, 10 percent mediocre, and 5 percent poor. I was using a fixed bearing knee implant, and I had tried three different designs to try to help improve my outcomes.

In 2006, I used a com-puter navigation system called Brainlab and used a rotating platform pros-thesis by Depuy. (See fig-ure 6.) I saw my results climb to 92 percent good-to-excellent, 5 percent mediocre, and 2 percent

poor. The bottom 7 percent still had difficulty with stairs, going downhill, and kneeling. They also reported anterior knee pain. De-spite the use of the navigation, about 5 percent to 10 percent still had some midflexion instability.

In 2009, I changed computer navigation to Stryker, and I started to use the roundabout or Triathlon knee. (See figure 7.) The design of this implant was to allow for the ligaments to stay at a constant length through a full arc of motion, which would take away midflexion instability and therefore improve one’s ability to use stairs, kneel, and so forth. The computer was easier to navigate and actually improved efficiency in the operating room. Now my results are 98 percent good-to-excellent, 1.5 percent mediocre, and less than 0.5 percent poor.

Robotic surgery is currently being used to perform total hip replacements and partial knee replacements. Two companies are most commonly used: Mako (now owned by Stryker) and Blue Belt. (See figures 8 and 9.) The application for total knee replacement is expected to be released in the next year or two. The development of tech-

niques that improve efficiency and outcomes will be essential as the number of orthopaedic surgeons will diminish, while the need for total knee replacement will increase. Currently, busy orthopaedic surgeons are capable of performing up to 10 total

knee replacements in a day. I foresee in the next 5 to 10 years that very busy orthopaedic sur-geons will be doing 10 to 15 total knee replace-ments daily, and up to 50 percent of the pro-cedures will be done on an outpatient basis.

The ideal knee arthroplasty is not a replacement with metals, plastics, or any other man-made device. The normal knee has a coefficient of friction 50X lower than any man-made device. The ideal arthroplasty would be to grow one’s own cartilage back to a normal state. Much research has been invested in this, and a recent recipient in 2012 for the Nobel Prize in Medicine was a Japanese orthopaedic surgeon, Dr. Shinya Yamanaka, who discovered that you can take a mature cell and turn it back into an immature or stem cell. The implications of this could have a dramatic affect on treating arthritis, cancer, and aging.


Figure 7: Stryker Triathlon Knee using Computer Navigation

Figure 8: Mako Robotic Technology (now owned by Stryker)

Colin M. Kingston, MD, FAAOS, CAQSM, is a specialist in Sports Medicine, General Orthopaedic Surgery, and Joint Replacement. He attended medical school at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and his residency at the Uniformed Services Health Consortium in San Antonio, Texas. Dr. Kingston earned his undergraduate degree from State University of New York at Albany. He has been with Tidewater Orthopaedics since 2003.

Figure 9: Bluebelt Robotic Technology

Figure 6: Depuy Rotating Platform Sigma Knee and Brainlab Computer Knee Navigation System

Figure 5

Exactech Shoulder Replacements10 Years of Clinical Use

Designed to:• Help match each individual patient’s

bone structure• Work in a variety of procedures• Address unique clinical challenges• Preserve a patient’s natural anatomy

There are many factors that contribute to the overall success of joint replacement surgery. With any surgery, there are potential risks, and results will vary depending on the patient. Joint replacement surgery is not for everyone. Check with your physician to determine if you are a candidate for joint replacement surgery. Your physician will consider the risks and benefits associated with joint replacement, as well as individual factors such as the cause of your condition, and your age, height, weight and activity level.

FIND AN ORTHOPAEDIC SURGEON NEAR YOU.GetBackToWhatYouLove.comGET BACK

TO WHATYOU LOVE

Recent clinical research by the Steadman Philippon Research Institute demonstrated that the Unloader One decreases pain, improves function and reduces the usage of pain medication.*Study available at www.ossur.com.

At 6 months, the below percentages of patients reported a reduction in medication use:

* Briggs, K.K., Matheny, L.M., Steadman, J.R., 2012. Improvement in quality of life with use of an unloader knee brace in active patients with OA: A prospective cohort study. J Knee Surg 25, 417-422.

OF PATIENTS

OTC ANTI-INFLAMMATORIES

OF PATIENTS

PRESCRIPTION ANTI-INFLAMMATORIES

OF PATIENTS

PAINMEDICATIONS

1 Decreased pain For a more active life2 Improved function Helping to postpone surgery3 Reduced pain medications Avoiding unwanted side effects

1 2 3

Contact your local Össur representative, Aubrey Williams, to learn more about the complete bracing line from Össur OA.

Phone: 757.771.2676Email: [email protected]

ÖSSUR OA UNLOADER ONE®

The most clinically proven Osteoarthritis brace

Tidewater Ortho Ad.indd 1 4/9/13 3:20 PM

THEAPPRENTICE SCHOOL

CRAFTSMANSHIP • SCHOLARSHIP • LEADERSHIP

TUITION-FREE • FULL -TIME BENEFITS • FULL -TIME PAYEarn while you learn. Division III Level Athletics.

FOR MORE INFORMATION VISITwww.as.edu


10 • Orthopaedics: A Tidewater Update 10 • Orthopaedics: A Tidewater Update

SHOuLdEr SurGErYan Outpatient Procedure?

NOT long ago, most orthopaedic surgeries involved a lengthy stay in the hospital. For example, it was not unusual for people with

total shoulder replacement to remain several days to begin their recovery. Even patients with rotator cuff repairs and labral repair surgeries stayed in the hospital overnight.

With incredible recent advancements in surgical techniques and pain management, more and more surgeries are being done as an outpatient procedure. For me, in fact, the only shoulder surgery I performed that involved an overnight stay in the hospital was a total shoulder replacement—that is, until recently.

My introduction to shoulder replacements as an outpatient procedure was actually driven by one of my patients. She was a healthy lady who unfortunately suffered a bad shoulder fracture. We tried to treat her without surgery, but her pain was too severe and her function was too poor. During my pre-operative evaluation, she expressed the desire to go home after surgery. Like many people, she felt that she would be better able to recuperate at home in her familiar surroundings. Because the nerve blocks we give before surgery give excellent pain relief, and patients were typically just receiving pain medications by mouth (something they

By Nicholas K. Sablan, MD


Nicholas K. Sablan, MD, FAAOS, completed his residency in orthopaedic surgery at the Univer-sity of Connecticut, and a fellowship in orthopae-dic sports medicine in the Kerlan Jobe clinic in Los Angeles. In Los Angeles, Dr. Sablan served as assistant team physician to the Lakers, LA Kings, Anaheim Ducks, Los Angeles Dodgers and PGA Tour as well as college and high school sports teams. He joined Tidewater Ortho in 2011 because he shares their same commitment to providing excellent subspecialty care.

could easily do at home), I thought it was a reasonable request. However, I did reserve a bed for the patient, just in case she changed her mind!

In the recovery room after surgery, the patient was in no pain and was tolerating her food. She again asked to go home. After careful thought, I said yes. The first few days, I called her frequently, and each time she said her pain was well under control. She was sleeping better—people usually do in their own bed—and her husband’s home cooking was better than anything she could get in the hospital. She could also wear her own clothes instead of a gown, and she could use her own private restroom. How could that not be a better option?

A lot of effort has been put into getting to this point. Most shoulder procedures can now be done arthroscopically through small stab incisions that are much less traumatic to the body than more traditional open techniques. We are doing most of our surgery at a hospital that is dedicated to caring for orthopaedic surgery patients. We are now doing nerve blocks on all of our shoulder surgery patients, and for select cases we are even leaving in a pain pump to provide longer lasting pain relief.

For shoulder replacements, we use medications that limit blood loss during surgery. As a result, we no longer administer blood transfusions. We have home health care options as well as excellent therapists in our office that help our patients as soon as possible.

Although not everyone is a candidate for outpatient shoulder replacement, I am finding more and more patients interested in this option. The future of shoulder surgery is indeed exciting!

With incredible recent advancements in surgical techniques and pain management, more and more surgeries are being done as an outpatient procedure.”

We help our patients

REACH their goals!

Now open in Williamsburg211 Bulifants Blvd., Suite B

(Michael Commons – near Sentara Hospital)595-9800

Whether you are looking to regain lost freedom or establish new goals, we are here to help!

Newport News11747 Jefferson Ave., Suite 5A

595-9800

Chesapeake4057 Taylor Rd., Suite P

673-2000

Call 595-9800 for appointment

www.reachops.com

ALL OF OUR CLINICIANS ARE CERTIFIED BY THE AMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS, PROSTHETICS AND PEDORTHICS

SERVICES:

• Custom Made Orthotics • Specialists in State-of-the-Art

Innovation for Upper and Lower Prostheses

• Pediatric – Geriatric • Preventative & Rehabilitative• Locally Owned and Operated


MANuAL PhySICAL ThERAPyuses in Orthopaedic Practice

MANUAL Physical Therapy is a specialized form of treatment that is administered with the hands. In manual therapy, practitioners use their hands or use instrument-

assisted manual techniques to put pressure on muscle tissue and/or manipulate joints in an attempt to decrease pain caused by muscle spasm, muscle tension, muscular trigger points, and joint dysfunction.

Manual therapists approach the restoration of function from the perspective that exercise is not the driving mode of recovery but a complement to manual therapy. These therapists are interested in why a muscle isn’t functioning properly, and they look to restore proper movement and function through the use of a variety of manual techniques, exercise, and modalities. These techniques can be inspired by old principles or developed through new and innovative thought processes.

At Tidewater Orthopaedics, we are proud to practice manual medicine in our outpatient orthopaedic physical therapy clinics. We have recently introduced two new manual techniques that are available for our physicians to prescribe to patients in order

to reduce pain and restore function. These techniques include Trigger Point Dry Needling (TDN) and The Graston Technique.®*

Trigger Point Dry (TDN) needling has commonly been used by physical therapists around the world to treat myofascial trigger points. However, the technique has been practiced in the United States only for the last five to ten years. Physical therapists who have been adequately trained in dry needling are successfully employing the technique with a wide variety of patients.

Dry needling is used primarily in the treatment of myofascial trigger points (MTrPs), which are defined as hyper irritable spots in skeletal muscle associated with hypersensitive palpable nodules. Myofascial trigger points are often responsible for complaints of pain in people with neck and/or back pain, shoulder pain, tennis/golfers elbow, headaches, hip and gluteal pain, knee pain, Achilles tendonitis/tendonosis, plantar fasciitis, and sciatica, to name a few of the diagnosis which can be treated with TDN.

Trigger Point Dry Needling is based on Western medical research and principles, whereas acupuncture is based on traditional

By Lindsay Gray, DPT

Graston Tools Graston Technique


Chinese medicine. Acupuncture and TDN are taught in separate institutions, with each therapy having separate and distinct methodology, perspectives, and practices. However, the same sterile, disposable solid filament needles are used in both disciplines.

TDN uses a small solid filament needle, which is inserted in a contracted painful knotted muscle to create a local twitch reflex, which is both diagnostic and therapeutic. It is often the first step in breaking the pain cycle. Research shows that this response will decrease muscle contraction, reduce chemical irritation, improve flexibility, and decrease pain. Dry needling of a MTrP is considered most effective, when local twitch responses (LTR) are elicited. Patients commonly describe an immediate reduction or elimination of the pain complaint after eliciting LTRs. Once the pain is reduced, patients can start active stretching, strengthening, and stabilization programs.

The Graston Technique®, invented by an athlete named David Graston, is an instrument assisted form of manual therapy. Specially designed instruments are used to identify and treat soft tissue injury. This technique is often employed by chiropractors, osteopathic physicians, physical therapists, occupational therapists, and some licensed massage therapists and athletic trainers.

The general goal of the Graston Technique® therapy is to reduce the patient’s pain and increase function through a combination of (1) breaking down scar tissue and fascial restrictions often

associated with some form of trauma to the soft tissue, (2) reducing restrictions by stretching connective tissue in an attempt to rearrange the structure of the soft tissue being treated, and (3) promoting a better healing environment for the injured soft tissue.

Potential benefits and advantages of the Graston Technique® are many, including decreasing overall treatment time, fostering faster rehabilitation and recovery, reducing the need for medication, and resolving chronic conditions thought to be permanent. This treatment is also used in conjunction with flexibility, strengthening and stabilization exercises as well as modality treatment in order to achieve the best outcomes.

* Copyright 2009 Graston Technique®

TPTI.comftrix

To learn more, visit: TPTI.com/programs/aquatic-therapy

THE HEALING POWER

As part of a comprehensive physical therapy program, aquatic therapy is an effective treatment option to

minimize joint impact and speed recovery. Our heated pools with submerged treadmills help you enjoy the benefits of physical therapy with less pain.

Make your own appointment today!

THE HEALING POWERAquatic Therapists

Aquatic Centerand Aquatic Centerand

of water5 AQUATIC THERAPY LOCATIONSSuffolk.................................................Franklin...............................................Williamsburg.......................................Newport News - Oyster Point.............. Virginia Beach - First Colonial..............

Aquatic Therapists

757.539.6300 757.562.0990 757.220.8383 757.873.2123 757.961.4800

Back Pain Arthritis Fibromyalgia Osteoporosis Joint Replacements Joint Pain or Stiffness Muscle Spasms Pain in Pregnancy

Aquatic Centerand Aquatic Centerand

Lindsay Gray, DPT joined Tidewater Orthopae-dics as the Director of Physical Therapy in 2014 having worked in the field of physical therapy for 20 years. She brings with her a vast expe-rience in physical therapy from Home Health to Rehab Services. Ms. Gray also holds a Masters of Education and a Masters of Business Administration. Her efforts to expand services at Tidewater Orthopaedics Physical Therapy can be seen with new manual therapies now being offered.

NOW that I am officially a “Kingston Quad”—having had both my knees and my hips re-

placed, all at the hand of Dr. Kingston and his staff—I am writing this to say thank you for changing my life! Actu-ally, I should say “changing our lives,” since when my wife needed a knee replacement there was no question as to who would perform the procedure. I recommend Tidewater Orthopaedics to anyone!

Now that I am an experienced total joint replacement expert, and I can tell you that no two joint replacements are the same. I would like to share with you what I have come to expect from the outstanding staff at Tidewater Orthopaedics—nothing less than great people, great service, and a lot of support and care when you need it the most.

To fully understand my story, you would have to go back more than 30 years ago, when I was young, active, and literally half the man I am today. (Yes, I am much larger than the average bear). I played basketball, baseball, racquetball, and I even trained for a marathon when living in Hawaii.

However, life brought several changes through a motorcycle accident and several different sports injuries that left me restricted in movement. Today, with my new joints, I am slowly getting back into cycling and kayaking, and I am enjoying it more than ever. My advice to others would be, don’t sit down and let life pass you by!

For my fourth and final replacement (unless my shoulder gives out), I tried a different physical therapy group than in the past, with much better results. After my first three surgeries, I chose a physical therapy group that was

closer to where I live, but this time I tried Tidewater Orthopaedic’s own physical therapy practice. I am glad I did. Just like the rest of the staff, the physical therapy group at Tidewater is top-notch and very pleasant to deal with. Without cutting any corners, I was able to finish ahead of schedule!

There is a lot to consider when you need a full joint replace-ment. But if you ask me, I would look no further than Dr. Kingston and his outstanding staff. From the first visit to the last, you will find no better place to get your life back than at Tidewater Orthopaedics.


From Our Patients

By Christopher Beardsley

“Thank You for Changing My Life!”

ThOMAS Wessells, Ed.D is a resident of Newport News and can be found busy at work as a licensed professional counselor at Rock Landing Psychological Group. He can

also be found doing great after a successful rotator cuff repair by Dr. Colin Kingston last August. And just in time for spring fly fishing! After suffering a rotator cuff tear while on a very intensive saltwater fishing trip to Belize and a subsequent repair, Dr. Wessells is back to pursuing his passions, fishing and creating and building furniture.

Dr. Wessells first came to see Dr. Kingston for some knee problems and has been receiving injections to relieve his symptoms. Throughout his life Dr. Wessells has been a very active man, participating in many outdoor sporting activities as well as a furniture building business. It seems all the wear and tear caught up with him on an extended and very strenuous fishing trip to Belize when he suffered a rotator cuff tear. After his rotator cuff repair in August he underwent Physical Therapy and by Thanksgiving he was asking Dr. Kingston if he was ready to fish again. This time he was off on a fly fishing trip

which although less strenuous than his saltwater fishing trip, still required a shoulder in good repair. Dr. Wessells didn’t over do it, but enjoyed himself none the less and is now back to his furniture business and up in the rolling hills of Virginia fly fishing again.

As told by Thomas Wessells, Ed.D

Pursuing my Passions

NANETTE Polas holds a special place in the history of Tidewater Orthopaedics. Although she has been a patient for several years, in February 2015 she became not only

the first patient at Tidewater Orthopaedics to have a partial knee replacement using the Navio robotic-assisted system; she became the first such patient in the state of Virginia.

A few years ago, Nanette came to Tidewater Orthopaedics because of problems she had with her right knee. Those problems were resolved, but left knee issues brought her back to see Dr. Michael Higgins. After diagnostic testing in January 2015, Dr. Higgins discussed treatment options with Nanette. Although cortisone injections were offered to provide some relief, he told Nanette that without further treatment it was likely that her condition would get worse. She would continue to deal with weakness and would be susceptible to falls.

Dr. Higgins told Nanette about the newest treatment option for knee replacement—the Navio robotic-assisted technique, which is now available at the Orthopaedic Hospital at Sentara CarePlex. Surgery was scheduled and Nanette (along with her husband) attended a class preparing her for the experience.

Nanette cannot say enough good things about her en-tire experience at the Ortho-paedic Hospital at Sentara CarePlex—from the class that prepared her for what to expect before, during, and after surgery, to the nurses and physical therapists who cared for her during the day and a half she spent at the hospital. “They treated me like family,” Nanette says. All her expectations were met and exceeded, and she has had a very quick recovery.

After only a couple weeks of physical therapy Nanette is traveling, visiting friends, and entertaining family. She is proud to be the first patient in Virginia to benefit from the Navio robotic system, and Tidewater Orthopaedics is exceptionally pleased she is doing so well.


As told by Nanette Polas

First Patient in Virginia to use the Navio robotic System

MR. James Granger, a Poquoson resident, has a very interesting past. He was an Indian Dancer as a youth, then as a square-rigger sailor in the Coast Guard he could be found climbing up rigging. Once commissioned, he spent years standing

on steel decks. As a result he really mistreated his legs. Even with all of this mistreatment to legs and feet, Mr. Granger was walking 3 miles every day until the pain stopped him. Dr. Michael Higgins, assisted by the Navio Robot, installed a STRIDE Partial Knee Implant on 2/16/2015, and Mr. Granger used a walker to leave the Orthopaedic Hospital at Sentara Careplex about 30 hours after he entered. Now he stands for many hours on his new knee, and it’s doing great. But the OTHER knee wants the same attention, since it has the same mileage. He wants to take a trip this summer, so he plans to have the other knee replaced by Dr. Higgins. He jokes “I’ve already made it clear I expect a Volume Discount”!

James Granger is a very active 82-year old Retired Coast Guardsman. He says he is “trying to be an artist”. He is currently finishing the last two of a seven paintings series of Omaha Beach and La Cambe German war cemetery in France, has 2 paintings hanging in the Blue Skies Gallery in Hampton, and 7 others hanging in The Plaid Turnip in Suffolk and he is submitting 3 for the Art Institute of Virginia Beach Exhibit coming this summer. Mr. Granger is also a very active volunteer serving on his Condo Board of Directors, volunteering several hours at LAFB Satellite Pharmacy, and he can be found at the Charles H. Taylor Art Center in Hampton for Art Classes.

To keep Mr. Granger active, Dr. Michael Higgins performed the Navio Partial Knee replacement procedure on him this past February making Mr. Granger the 1000 in the world recipient! According to Mr. Granger, “I’ve been singing his praises to everybody I meet, showing them my scar, raving about the Navio robot in general, and Dr. Michael Higgins in particular”.

As told by James Granger

A New Knee Keeps this Busy retiree Moving


CArPAL TuNNEL SYNdrOMESymptoms, Diagnosis, and Treatment

CARPAL tunnel syndrome is characterized by a combination of symptoms in the arm, hand, and fingers. These include numbness,

tingling, and pain due to compression of the median nerve at the wrist.

The median nerve provides feeling and movement to the “thumb side” of the hand. The area at the base of the palm where the nerve enters the hand is the carpal tunnel. If swelling builds in the tunnel, pressure develops on the nerve and disturbs its function. “Idiopathic” carpal tunnel syndrome occurs when there are no identifiable systemic or local factors causing the pressure on the median nerve.

The cause of carpal tunnel syndrome continues to be a matter of debate. Scientific evidence implicates structural, genetic, and biological factors. Environmen-tal and occupational factors lack such evidence, and thus play a minor role, if any.

Symptoms. The symptoms of carpal tunnel syndrome include sensory and motor dysfunction. Numbness or tingling most often occurs in the thumb, index finger, middle finger, and ring finger. The numbness or tingling are frequently noticed at night but may also occur during daily activities, such as when driving or reading a newspaper. The result is a weaker grip, which at times is observed in a tendency to drop objects. The muscles at the base of the thumb can slowly shrink, resulting in difficulty with pinch. In severe cases, sensation is permanently lost.

diagnosis. The clinical criteria for the diagnosis of carpal tunnel syndrome include numbness and tingling in the median nerve distribution; nighttime numbness; weakness and/or atrophy of the thumb muscles; tinel’s sign (“pins and needles” in fingers when tapping over the nerve); phalen’s test (when forced wrist flexion results in “pins and needles” in fingers); loss of 2-point discrimination. If clinical testing is positive and surgery is considered, electro-diagnostic testing may be obtained to confirm carpal tunnel syndrome and to check for other possible nerve problems.By Nicholas A. Smerlis, MD

...patient satisfaction and improvement in symptoms and functional outcome after surgery remain quite high.”

Treatment. Treatment of carpal tunnel syndrome usually begins with considering non-surgical options. For example, wrist splints can reduce pressure on the nerve and relieve symptoms, especially at night. Steroid injections into the carpal tunnel can relieve symptoms by reducing the swelling around the nerve. Oral steroids, mobilization exercises, and ultrasound are also treatment options.

Surgery. When symptoms are severe or do not improve with

initial treatments, surgery may be needed to make more room for the nerve by releasing the ligament that forms the roof of the tunnel on the palm side of the hand. Incisions for surgery may vary, but the goal is the same: to enlarge the tunnel and decrease pressure on the nerve.

recovery. Following surgery, numbness and tingling may disappear quickly or gradually. It can take several months for strength of the hand and wrist to return. Soreness around the incisions might linger for several weeks or months, with a small subset persisting long-term. In some cases, the symptoms of carpal tunnel syndrome cannot be eliminated, especially in severe cases. Overall, however, patient satisfaction and improvement in symptoms and functional outcome after surgery remain quite high.

Hand specialists at Tidewater Orthopaedics will discuss with their patients realistic goals, possible risks, and expected results of any treatment being considered.


Count on

High treatment compliance1 >> + Successful fracture

healing outcomesProven clinical effectiveness2-4

*Summary of Indications for Use: The EXOGEN Ultrasound Bone Healing System is indicated for the non-invasive treatment of established non unions† excluding skull and vertebra. In addition, EXOGEN is indicated for accelerating the time to a healed fracture for fresh, closed, posteriorly displaced distal radius fractures and fresh, closed or Grade I open tibial diaphysis fractures in skeletally mature individuals when these fractures are orthopaedically managed by closed reduction and cast immobilization. There are no known contraindications for the EXOGEN device. Safety and effectiveness have not been established for individuals lacking skeletal maturity, pregnant or nursing women, patients with cardiac pacemakers, on fractures due to bone cancer, or on patients with poor blood circulation or clotting problems. Some patients may be sensitive to the ultrasound gel. Full prescribing information can be found in product labeling, at www.exogen.com, or by calling customer service at 1-800-836-4080.

†A non-union is considered to be established when the fracture site shows no visibly progressive signs of healing.

References: 1. As demonstrated in a non-union population of 101 patients. Schofer MD, Block JE, Aigner J, Schmelz A. Improved healing response in delayed unions of the tibia with low-intensity pulsed ultrasound: results of a randomized sham-controlled trial. BMC Musculoskelet Disord. 2010;11(1):229. 2. Heckman JD, Ryaby JP, McCabe J, et al. Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound. J Bone Joint Surg [Am]. 1994;76(1):26−34. 3. Kristiansen TK, Ryaby JP, McCabe J, et al. Accelerated healing of distal radial fractures with the use of specific, low-intensity ultrasound. A multicenter, prospective, randomized, double-blind, placebo-controlled study. J Bone Joint Surg [Am]. 1997;79(7):961−973. 4. Nolte PA, van der Krans A, Patka P, et al. Low-intensity pulsed ultrasound in the treatment of nonunions. J Trauma. 2001;51(4):693−703.

© 2015 Bioventus LLC EXOGEN is a registered trademark of Bioventus LLC.

Nicholas Smerlis, MD, FAAOS, CAQSH, is a board-certified, orthopaedic surgeon with subspecialty certification in surgery of the hand. He completed a fellowship in hand and upper extremity at Wake Forest University Baptist Medical Center and has been with Tidewater Orthopaedics since 2007 practicing solely on the hand & wrist.


PhySICIAN ExTENDERSImprove Patient Access and Care

DURING the next decade, the United States can expect to see a shortage of orthopaedic surgeons. The reason is twofold: (1) aging Baby Boomers and (2) the continually

growing number of uninsured who are being covered by universal healthcare programs.

A third of all practicing orthopaedic surgeons are over 55 years of age, and many of these will retire during the next 10 years. Younger orthopaedic surgeons are listing “lifestyle,” “time off,” and “decreased call burden” as top priorities when seeking employment. When combined, these factors raise serious concerns about the future for orthopaedic surgery.



The role of Physician ExtendersThe goal of all practicing orthopaedic surgeons is to improve clinical and surgical efficiency while not compromising quality care. To accomplish this, the orthopaedic field will have a continual need for physician extenders—physician assistants and nurse practitioners. Tidewater Orthopaedics is at the forefront of achieving that objective. Consider:

A busy orthopaedic surgeon may see a patient with a minor sprain and then have his medical assistant put on a brace and follow up with the patient as needed. A physician extender would show the patient how to put on the brace and answer any questions the patient may have about expectations. As a result, the orthopaedic surgeon has more time to spend with patients with more complex issues.

With the help of physician extenders, operating-room efficiency is improved significantly. Patients spend less time under anesthesia, less time with open wounds, have fewer complications, and experience better outcomes. Consider in more detail the role of physician extenders.

Nurse Practitioners A Nurse Practitioner (NP) can evaluate and treat patients who have a variety of medical conditions without the supervision of a physician. Nurse Practitioners are fully registered and have a graduate degree in advanced practice nursing. They work predominantly in a clinical setting and can either work in primary care or specialize in fields such as orthopaedics. The Nurse Practitioner can diagnose diseases and injuries, initiate treatment plans, order diagnostic and lab tests, perform minor procedures, and prescribe medications.

At Tidewater Orthopaedics, we will utilize our Nurse Practitio-ners primarily in the field of the upper extremity arena, but we will expand their role to other subspecialty areas as the need arises. A board-certified hand surgeon is readily available around the clock for cases that (1) require more oversight, (2) are more complex than the original triage working diagnosis described, or (3) require urgent surgical intervention. Our encrypted e-mail and commu-nication system allows the Nurse Practitioner to consult with the hand surgeon, even when the two are at different locations. This enhances the patient’s access to the best care available on the peninsula.

Physician AssistantsThe Physician Assistant (PA) is a nationally certified and state licensed medical professional. There are now more than 95,000 Physician Assistants in the United States, and they consult with an estimated 7 million patients per week. Physician Assistants work under the supervision of a physician. Their scope of practice is similar to that of a physician and is dependent on the state in which they practice. Their educational background includes receiving four years of undergraduate training, attending an accredited physician assistant program for 25 months, and completing one- year clinical rotation in order to obtain a license.

Physician Assistants must complete ongoing educational classes and get re-tested on their medical expertise in order to maintain

their license. The tests are on general medical knowledge, even if the Physician Assistant specializes. Many specialists, such as orthopaedic surgeons, rely on the Physician Assistant’s general medical knowledge in optimizing patient care.

For example, the Physician Assistant will often consult a cardi-ologist prior to surgery if a previously undiagnosed heart murmur was detected on the patient’s physical exam. Physician Assistants can also assist surgeons in the operating room. This improves op-erating room efficiency and therefore improves patient experience and outcomes. Physician Assistants also make rounds on patients and help manage their medical issues.

What are the differences between a Nurse Practitioner and a Physician Assistant? In general, both Nurse Practitioners and Physician Assistants practice with full autonomy. Nurse Practitioners are independent practitioners, meaning that they do not need the supervision of a physician. Physician Assistants are dependent practitioners; they are sponsored by a physician, can assist in surgery, and can be on call. The quality of care that Nurse Practitioners and Physician Assistants offer will enhance the overall patient experience at Tidewater Orthopaedics.

All of our healthcare providers provide injections into patient’s joints with cortisone, lubricants, or growth factors like Platelet Rich Plasma (PRP). One provider, Amanda Watkins,PA-C stands out continually in our patient surveys as one of the best at these procedures. Our established patients are thankful for the high-quality care she provides with improved access and less waiting.

We proudly welcome Lindsey Townsend (PA-C) and Laurie LeBel (FNP-BC), our newest physician extenders. Amanda Watkins (PA-C) has been with Tidewater Orthopaedics since 2010, and Susan Walkley (CNP) since August 2013.

The goal of all practicing orthopaedic surgeons is to improve clinical and surgical efficiency while not compromising quality care.”


What is a “CErTIFICATION OF AddEd QuALIFICATION” in Orthopaedic Surgery?


WE at Tidewater Orthopaedics refer to ourselves as “The Specialist Group.” That term well describes our objective to attract and maintain orthopaedic surgeons who can provide

expert subspecialty care to the region. As the complexity of orthopaedic surgery continues to grow, we recognize the difficulty of being expert in all aspects of musculoskeletal care.

The Certification of Added Qualification (CAQ) acknowledges an orthopaedic surgeon’s expertise within a subspecialty area. Not every orthopaedic surgeon is eligible for sub-specialization. Currently, the field of orthopaedics offers two CAQs—one in sports medicine and the other in hand surgery. The website of the American Academy of Orthopaedic Surgeons (AAOS) states that these subspecialty certificates are “for board-certified orthopaedists who have demonstrated significant qualifications in the subspecialty area through additional training, who have a practice focused on the subspecialty category, and who have made contributions to the field.”

What are the requirements for a board-certified orthopaedist to receive a Certification of Added Qualification? The AAOS website states:

“You must do the following to be eligible to take a subspecialty certificate examination:

• Complete a 1-year Accreditation Council for Graduate Medical Education-accredited fellowship in the specialty.

• For sports medicine, submit a 1-year case list of at least 115 surgical cases and 10 nonsurgical cases; at least 75 of the 115 surgical cases must involve arthroscopy as a component of the procedure.

• For surgery of the hand, submit a 1-year case list of at least 125 cases that meet the required number of cases in six of nine categories.

• Applications for the subspecialty certificate examination become



afterballoon kyphoplastybefore

Take ChargeDon’t Turn Your Back on Back Pain

Although the complication rate has been demonstrated to be low, there are risks associated with the procedure, including serious complications some of which, though rare, may be fatal. These include, but are not limited to, heart attack, cardiac arrest and stroke. Other possible complications include infection and leakage of bone cement which may result in damage to blood vessels, lungs, heart, brain and, in rare instances, cause paralysis. Your physician can provide more information and can help determine whether you may be a candidate for this procedure.

If you’re over 50 or have osteoporosis, it’s important that you don’t ignore your back pain. It may signal a spinal fracture. See your doctor right away if you think you may have one.

Spinal fractures can be repaired if diagnosed. Kyphon® Balloon Kyphoplasty is a minimally invasive treatment for spinal fractures that can restore vertebral body height, reduce painand improve patient quality of life.

Visit www.spinalfracture.com to find a specialist in your area.

©2015 Medtronic Spine LLC. All rights reserved. PMD009988-1.0

31493 KYPHON BKP Take Charge Ad 4_9x3_7125.indd 1 4/14/15 10:31 AM

available on www.abos.org each August. The 4-hour examination, which is computer-based and consists of approximately 200 multiple-choice questions that evaluate cognitive knowledge related to the subspecialty, is administered the following fall.

• If you pass the subspecialty certification examination, you will receive a certificate valid for 10 years, as long as you also maintain your board certification.”

The CAQ in sports medicine was available to select board certified orthopaedic surgeons who specialized in sports medicine but who had not completed a one-year fellowship, having had that particular criteria waivered. I was one of those who, like many at the time, did not have an additional year of training. However, in the years that followed I acquired significant experience in the field of sports medicine and could thus be eligible for receiving a Certificate of Added Qualification.

The process selects only board-certified orthopaedic surgeons who qualify and pass the exam. Currently, Tidewater Orthopaedics has three physicians who have done so: myself and our two hand surgeons, Dr. Nicholas Smerlis and Dr. Robert Campolattaro. Dr. Loel Payne and Dr. Nicholas Sablan are eligible to apply for their CAQ in sports medicine, as they meet the above criteria. Currently, there are no CAQs for other sub-specialty areas within orthopaedics.

At Tidewater Orthopaedics, we pride ourselves in our ability to get patients to the right physician who is the regional expert within that particular aspect of musculoskeletal care. To do that in a relatively low-populated area such as the Tidewater region has not been easy, but it is at the very core of our mission to provide the highest quality care.


Thank You To Our Sponsors

Careplex Orthopaedic Ambulatory Surgery Center

dJO, LLC

Euflexxa

Exactech

Exogen/Bioventus LLC

Hope In-Home Care

Medtronic

Ossur

reach Orthotics & Prosthetic Services

record reproduction Services

Stryker

The Apprentice School

Tidewater Physical Therapy


The Challenge of TreatingFINGErTIP INJurIES

MANY people take the fingertip for granted, but it is constantly exposed—and vulnerable—during most of our daily activities. Not surprisingly, therefore, fingertip injury

is one of the more common injuries in the hand. Fingertips can be damaged by a closing door, a hammer, or a heavy object that is dropped onto it. The finger is also susceptible to being cut with a knife or a power tool, such as a saw or a lawnmower.

Injured components of the finger may include the skin, bone, nail, nail bed, tendon, and the pulp. (See Figure 1.) The pulp is the padded area of the fingertip, which affords it adequate protection. The nail also protects the fingertip, as it helps in the regulation of peripheral circulation and contributes to the tactile sensation that enables us to pick up small objects. The tendons are cord-like structures that connect the muscles from the forearm to allow us to move the fingertip.

When a finger is injured, an examination will reveal the extent of tissue damage and its size. The viability of the tip is assessed by its circulation. Sensation is also a crucial factor in the exam, since the skin on the palm side of the fingertip is specialized with more nerve endings than most parts of our body. Tendon function is checked by the mobility of the tip. An x-ray will reveal whether there is any injury to the bone.

The goal of any treatment is to restore the anatomy of the nail and its surrounding structures to create a fingertip with durable sensate skin. At times, a crush injury to a fingertip causes only a subungal hematoma (blood beneath the nail) due to a cut in the nail bed. If the nail is intact, pressure within this confined space can frequently cause severe throbbing pain, and evacuation of the hematoma is indicated by making a small hole in the nail. With a significant subungal hematoma, however, the nail may need to be removed to repair the underlying laceration in the nail bed.

Severe crush or avulsion injuries can completely remove some or all of the tissue at the fingertip. Even if a small amount of bone is

exposed, the injury can be managed with simple dressing changes after the exposed bone is slightly trimmed back. For larger defects, skin grafting or alternative coverage is occasionally recommended.

Fractures of the bone in the tip of the finger are common. Very small fractures of the end or tuft of the bone usually do not affect the strength of the bone. If it is not significantly displaced, then simple supportive measures may be used. Otherwise, repair of the soft tissue (such as the nail bed) usually realigns and stabilizes the bone fragments. Fractures closer to the joint may require a splint or a temporary pin to hold the bone fragments in proper position. Tendon injuries are addressed with either splinting or repair. If the damage is too severe, amputation of the fingertip may be necessary.

The final appearance and function of the nail and surrounding structures depends on the ability to restore normal anatomy. Typical-ly, three to six months are needed for the nail to grow from the cuticle to the tip of the fin-ger. Fingertip insensitivity is common and may last for many months. The contour may have some distortion and the quality and texture of skin may be different. Stiffness can be a con-cern. Occupational therapy may be necessary to hasten the return to a productive lifestyle.

Before any treatment, hand specialists at Tidewater Orthopaedics will discuss with the patient realistic goals, possible risks, and expected results.

By Nicholas A. Smerlis, MD


Figure 1


RRSIS PROUD TO BE SERVING

SECURE... EFFICIENT... RELIABLE

RELEASE OF INFORMATION SERVICES

» Guaranteed Revenue

» Excellent Customer Service

» Extensive Audit Process» Quick Turnaround Time

» Flexible Delivery Options

» Real-time Status & Reporting

www.rrsmedical.com

Individual results vary. Not all patients will have the same post-operative recovery and activity level. See your orthopaedic surgeon to discuss your potential benefits and risks. Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: Stryker. All other trademarks are trademarks of their respective owners or holders. It may be time to get moving again.

NL10-AD-HI-3624

livingwithpain-directanteriorhip-half1 SC 7.625x4.9.indd 1 2/5/15 3:26 PM



Nicholas K. Sablan, MD, FAAOS, a board-certified orthopaedic surgeon who completed a fellowship in orthopaedic sports medicine at Kerlan Jobe Clinic in Los Angeles, has served as assistant team physician for the Los Angeles Lakers, the LA Dodgers, the LA Angels, and the PGA Tour, among others. He is the author of published multimedia on various shoulder topics including rotator cuff and AC joint injuries, as well as peer-reviewed publications and a book chapter on arthroplasty of the hip.

Nicholas K. Sablan, MD* • Shoulder and Sports Medicine

Robert Campolattaro, MD, FAAOS, CAQSH, is a board-certified, orthopaedic surgeon. He completed a fellowshipin hand and upper extremity at Wake Forest University Baptist Medical Center and has a practice that solely focuses on the treatment of hand and wrist conditions. Dr. Campolattaro is the current President of Tidewater Orthopaedics and was named “Top Doc of Hampton Roads” by Hampton Roads Magazine in 2013.

Robert M. Campolattaro, MD* • Hand and Wrist


Nicholas A. Smerlis, MD* • Hand and Wrist

Michael Higgins, MD, FAAOS, is a board-certified, orthopaedic surgeon. He completed a fellowship in joint replacement and reconstruction at the Roanoke Orthopaedic Center. He has written articles and lectured on hip and knee replacement. He has been named a Top Doctor by U.S. News & World Report. Dr. Higgins serves as the Orthopaedic Medical Director of the region’s only dedicated orthopaedic hospital.

Michael E. Higgins, MD* • Joint Replacements and Reconstruction

John McCarthy, MD, FAAOS, is a board-certified orthopaedic surgeon. He specializes in hip and knee replacements and has an interest in hand surgery. He completed a fellowship at the Hand Rehabilitation Center in Philadelphia. While practicing in Pittsburgh, PA, he served as a team physician for the Pittsburgh Penguins professional hockey team.

John J. McCarthy III, MD* • Joint Replacement and General Orthopaedics

Colin Kingston, MD, FAAOS, CAQSM, is a board-certified, orthopaedic surgeon. He completed medical school and his residency while serving in the United States Air Force. He has served in both gulf wars in Operation Southern Watch, Operation Enduring Freedom and Iraqi Freedom. He is also certified for Additional Qualification (CAQ) and CAQSM-Certificate of Added Qualifications in Sports Medicine. Dr. Kingston was named “Top Doc of Hampton Roads” by Hampton Roads Magazine in 2013 and 2014.

Colin M. Kingston, MD* • Sports Medicine and Joint Replacements

Amanda Watkins, PA-C

Amanda earned her undergraduate degree in Biology from the University of Nebraska where she was also a member of the Nebraska Army National Guard. During her time in the National Guard she deployed for Operation Iraqi Freedom where she joined a medivac unit as a flight medic. Amanda completed her Masters in Physician Assistant Studies at Massachusetts College of Pharmacy and Health Sciences. Following Graduate School Amanda joined Dartmouth Hitchcock focusing on Orthopaedics prior to moving to Hampton Roads to join Tidewater Orthopaedics in 2010.



Dr. Mason, a Norfolk, Virginia native, returns to Hampton Roads and joins the team of subspecialists at Tidewater Orthopaedics. He completed his residency training at the University of Virginia and his fellowship training at Twin Cities Spine Center in Minneapolis, Minnesota. Dr. Mason sees patients in both office locations and performs surgery at the Orthopaedic Hospital at Sentara CarePlex. Dr. Mason brings minimally invasive outpatient spine surgery to Tidewater Orthopaedics and many other cutting edge treatments for spine problems.

Jonathan R. Mason, MD • Spine

Loel Payne, MD, FAAOS, is a board-certified, orthopaedic surgeon who focuses his orthopaedic care on the treatment of the shoulder and knee. Dr. Payne attended undergraduate school at Duke University and medical school at the University of North Carolina Chapel Hill. He completed a fellowship in shoulder surgery and sports medicine at the Hospital for Special Surgery in New York. Dr. Payne has written multiple articles and book chapters and lectured nationally on shoulder conditions and has been with Tidewater Orthopaedics for almost 20 years.

Loel Z. Payne, MD* • Shoulder and Knee

Dr. Maloof attended New Jersey Medical School for medical school and his residency, where he served as Administrative Chief Resident in one of the busiest level one trauma centers on the east coast. He has completed his fellowship training in Foot & Ankle Surgery at Duke University. Duke is known as a pioneer in ankle replacement surgery and has brought this procedure to Hampton Roads along with numerous other cutting-edge treatments for various foot and ankle disorders.

Paul B. Maloof, MD • Foot & Ankle Orthopaedic Surgeon

* Board-Certified Orthopaedic Surgeon • FAAOS - Fellow of the American Academy of Orthopaedic SurgeonsCAQSM - Certificate of Added Qualifications in Sports Medicine • CAQSH - Certificate of Added Qualifications in Surgery of the Hand

Lauri LeBel, FNP

Lauri LeBel is a certified Family Nurse Practitioner who received her Nursing degree and Master’s degree from VCU. Prior to joining Tidewater Orthopaedics in 2014, NP LeBel practiced with a family practice in Gloucester, VA. She brings nearly 20 years of experience as a certified Family Nurse Practitioner to her new role with Tidewater Orthopaedics.

Lindsey Townsend, PA-C

PA Townsend attended Virginia Tech where she earned a Bachelor of Science in Human Nutrition, Foods, and Exercises. Upon graduating, she attended Shenandoah University and earned her Master’s degree in Physician Assistant studies. Prior to joining Tidewater Orthopaedics in 2015, she spent 8 years in her hometown of Richmond, Virginia at a large Orthopaedic practice where she specialized in issues pertaining to the lumbar spine. PA Townsend is a member of the American Academy of Physician Assistants and the Virginia Academy of Physician Assistants.

Susan Walkley, FNP

Susan Walkley, FNP is a Board Certified Nurse Practitioner and has been with Tidewater Orthopaedics since August 2013


An Awesome Team of Specialists and Staff

IN June 1996, I was hired at Tidewater Orthopaedics as a file clerk. I eventually transitioned to

a front desk position, and I am now working in checkout scheduling and authorizing diagnostic testing. I am coming up on my 19-year anniversary with Tidewater Orthopaedics, and we are stronger than ever!

When I was hired at Tidewater, there were only four physicians in the practice and some 50 employ-ees. Now we have nine physicians, two physician assistants, two nurse practitioners, physical and occupa-tional therapy offices, and more than a hundred employees. Working at Tidewater Orthopaedics provides me the opportunity to do what I enjoy most—helping people, wheth-er they are our patients or our staff. I have helped coordinate our Super Bowl pool as well as having won the chili cook-off that our practice holds each year. We have gone to baseball games together, planned and par-ticipated in Relay for Life, attended numerous Christmas party functions, and participated in many Halloween pranks! It’s all in good fun and makes the team more cohesive. I believe that those who play together work harder together!

My team includes Ambria and Phoebe. The three of us schedule patients for diagnostic testing and procedures. We also obtain authorizations from insurance companies for the procedures ordered by our physicians for the definitive care of their patients. We have an awesome team of specialists and an amazing staff to assist them. Together, we get the job done, and I am looking forward to many more years at Tidewater Orthopaedics.

Rose enjoys taking photos of her picturesque surroundings as she travels around scenic Hampton Roads. Tidewater Orthopaedics has displayed some of her recent photos in their Hampton office.

As told by Rose Revere

Working at Tidewater Orthopaedics provides me the opportunity to do what I enjoy most—helping people, whether they are our patients or our staff.”

NEWPORT NEWS , GLOUCESTER , WILLIAMSBURG, RICHMOND , VIRGINIA BEACH

Skilled Care Division (757) 873-3410Personal Care Division (757) 873-0030

• Orthopedic Post-op Care

• Skilled Nursing

• Certified Wound Care Nurse

• Orthopedic DME Equipment

• Physical Therapy

• Occupational Therapy

• Speech Therapy

• Medical Social Worker

• I.V. Therapy

• Personal Care

• Certified Nurse Assistants

• 24 Hr. On – Call Nurse

Hope In-Home Care

Ensuring Highest

Quality Care in

the Comfort of

Your Home

Tidewater Orthopaedics901 Enterprise Pkwy, Suite 900Hampton, VA 23666

rthopaedics · pdf filelic. the magazine will introduce the ... a specific patient-tailored...

Documents