Florida MD March/April 2023

MARCH/APRIL 2023 • COVERING THE I-4 CORRIDOR

Orlando Health Jewett Orthopedic Institute Downtown Complex

Orthopedic Leaders Open New Facility with Focus on Patient Care, Education and Research

YOU MAKE A WORLD OF

DIFFERENCE

CELEBRATING DAY

DOCTORS’ 2023

23-CFDNS-02237

Thank you for your selfless dedication to the health and well-being of those you care for, within our walls and beyond.

contents PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

4

MARCH/APRIL 2023 COVERING THE I-4 CORRIDOR

 COVER STORY

As the region’s largest orthopedic and sports medicine practice, Orlando Health Jewett Orthopedic Institute provides advanced orthopedic care to more than 250,000 patients each year. Physicians specialize in every area of orthopedics, including joint replacement, hand and upper extremities, foot and ankle, orthopedic trauma, spine, sports medicine, concussions, musculoskeletal radiology, bone health and anesthesia.

The Orlando Health Jewett Orthopedic Institute will begin welcoming patients to its new, downtown complex March 27. Located at the corner of Columbia St. and Lucerne Terrace in Orlando, the 375,000-square-foot, seven-story institute will be the first of its kind in the southeastern U.S. It provides every aspect of elective orthopedic care and world class physician training tools under one roof.

16

PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

ON THE COVER: Orlando Health Jewett Orthopedic Institute Downtown Complex

“We’re really excited to see this project come to life,” said Orlando Health Jewett Orthopedic Institute Physician President Dr. Michael Jablonski. “Physicians and other team members helped create the design, which is a unique feature of this facility. That insight will lead to a safer, efficient environment that promotes wellness and healing for our patients.”

WHEN THE TREMOR ISN’T ESSENTIAL – PARKINSON’S DISEASE: ONE OF THE MOST COMMONLY MISDIAGNOSED CONDITIONS

DEPARTMENTS 2

FROM THE PUBLISHER

8

DERMATOLOGY

9

HEALTHCARE LAW

12

PEDIATRICS

14

PULMONARY AND SLEEP DISORDERS

18

ORTHOPEDICS

FLORIDA MD - MARCH/APRIL 2023

1

FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. Sometimes a patient may have the opportunity to participate in a clinical trial. Sometimes a patient may need specialized treatment that is not available in Central Florida. And sometimes there’s no money for that patient to get to those places. Fortunately there is Angel Flight Southeast to get those patients where they need to go. I asked them to tell us about their organization and how you, as physicians, can help. Please join me in supporting this truly wonderful organization.

Best regards,

Donald B. Rauhofer Publisher

ANGELS ON EARTH HELP PATIENTS GET TO LIFESAVING MEDICAL TREATMENT Everyone knows angels have wings! But did you know in Florida and many parts of the nation they have engines and tails with dedicated volunteers who donate lifesaving services every day? Leesburg, Fla.-based Angel Flight Southeast is a network of approximately 650 pilots who volunteer their time, personal airplanes and fuel to help passengers get to far-from-home medical care. A member of the national Air Charity Network, Angel Flight Southeast has been flying passengers since 1993.

Almost all of its passengers are chronic-needs patients who require multiple, sometimes 25-50 treatments.

Passengers may be participating in clinical trials, may require post-transplant medical attention or are getting specialized treatment that is not available near home. Each passenger is vetted to confirm medical and financial need and is often referred to Angel Flight Southeast by medical personnel and social workers.

Angel Flight Southeast “Care Traffic Controllers” arrange flights 24 hours a day, 365 days a year. In the event of a transplant procedure, the Care Traffic Controllers have precious minutes to reach out to its list of volunteer pilots who have agreed to be prepared on a moment’s notice to fly a patient to receive his or her potentially lifesaving organ.

The organization is completely funded through donations by individuals and organizations. A typical Angel Flight Southeast pilot donates $400 to $500 in services-per-trip. In fact, Angel Flight Southeast has earned the Independent Charities of America Seal of Approval as a good steward of the funds it generates from the public.

Each $1 donated generates more than $10 worth of contributed services by Angel Flight Southeast.

The charity always seeks prospective passengers, volunteer pilots and donations. For additional information, please visit https://www.angelflightse.org or call 1-888-744.8263.

ADVERTISE IN FLORIDA MD

PREMIUM REPRINTS

For more information on advertising in Florida MD, call Publisher Donald Rauhofer at (407) 417-7400, fax (407) 977-7773 or info@floridamd www.floridamd.com

Reprints of cover articles or feature stories in Florida MD are ideal for promoting your company, practice, services and medical products. Increase your brand exposure with high quality, 4-color reprints to use as brochure inserts, promotional flyers, direct mail pieces, and trade show handouts. Call Florida MD for printing estimates.

Email press releases and all other related information to: info@floridamd.com

2 FLORIDA MD - MARCH/APRIL 2023

Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: John “Lucky” Meisenheimer, MD, Daniel T. Layish, MD, Jaivir S. Rathore, M.D, F.A.E.S, Idha Sood, M.B; B.S ; George J. Haidukewych, MD, Julie Tyk, JD, John Meisenheimer, VII Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information.

Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762.

Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2023 Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

The Best Nurses in Orlando.

choose well.

The only hospital in Orlando designated a Magnet Hospital for adult acute care by the American Nurses Credentialing Center (ANCC), Orlando Health Orlando Regional Medical Center provides the highest level of emergency and specialty services provided by an expert and compassionate clinical team.

OrlandoHealth.com/ORMC FLORIDA MD - MARCH/APRIL 2023 3

COVER STORY

Orlando Health Jewett Orthopedic Institute Downtown Complex – Orthopedic Leaders Open New Facility with Focus on Patient Care, Education and Research

By Staff Writer As the region’s largest orthopedic and sports medicine practice, Orlando Health Jewett Orthopedic Institute provides advanced orthopedic care to more than 250,000 patients each year. Physicians specialize in every area of orthopedics, including joint replacement, hand and upper extremities, foot and ankle, orthopedic trauma, spine, sports medicine, concussions, musculoskeletal radiology, bone health and anesthesia.

The Orlando Health Jewett Orthopedic Institute will begin welcoming patients to its new, downtown complex March 27.

Located at the corner of Columbia St. and Lucerne Terrace in Orlando, the 375,000-square-foot, seven-story institute will be the first of its kind in the southeastern U.S. It provides every aspect of elective orthopedic care and world class physician training tools under one roof.

“We’re really excited to see this project come to life,” said Orlando Health Jewett Orthopedic Institute Physician President Dr. Michael Jablonski. “Physicians and other team members helped create the design, which is a unique feature of this facility. That insight will lead to a safer, efficient environment that promotes wellness and healing for our patients.”

opening, set for August, will include the state’s first orthopedic specialty hospital and an education and research center.

“The Orlando Health Jewett Orthopedic Institute Downtown Complex provides an elevated level of orthopedic care for people in Central Florida and the surrounding region,” said Carlos Carrasco, president of the Orlando Health Jewett Orthopedic Institute. “This project combines world class physicians, state of the art technology and thoughtful dedication to safety and a patient’s experience.”

IMAGING Every detail of the institute has been designed to ensure the best experience for patients. For many, this begins with imaging.

Orlando Health is the first health system in Florida to receive MRI technology that will significantly accelerate scans and provide new entertainment options. When patients arrive for the MRI exam, they will be able to set mood lights inside the room.

The scan itself will be enhanced with augmented reality. Patients can immerse themselves in videos or music throughout the imaging experience, while a visible clock counts down their scan time.

According to Siemens, some knee exams can be completed in less than two minutes. “Most orthopedic patients are used to spending 30 to 40 minutes inside an MRI machine,” said Orlando Health Jewett Orthopedic Institute musThe 375,000-square-foot Orlando Health Jewett Orthopedic Institute Downtown Comculoskeletal radiologist Dr. Jonathan Kazam. “By plex is located at the corner of Columbia St. and Lucerne Terrace in Orlando. Phase significantly reducing scan time, we expect that 1 of the building opened March 27. Phase 2, which includes an orthopedic specialty patient comfort inside the MRI machine will be hospital, will open August 1. greatly enhanced, which will result in less motion and higher quality images.”

PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

During the phase 1 opening of the facility, patients can access imaging, lab and pharmacy services, a 62-exam room clinic, the ambulatory surgery center and rehabilitation space. The phase 2

ORTHOPEDIC CLINIC The orthopedic clinic includes 62 exam rooms, three procedure rooms, seven x-ray suites and two casting rooms. On average, 12 providers will staff the clinic daily, offering expertise in traumatology, spine, foot and ankle, hand, joint replacements, sports surgery, non-operative sports medicine, concussion management and pediatric sports medicine. The Orlando Health Jewett Orthopedic Institute employs highly-trained orthopedic and sports medicine physicians, many of whom completed sub-specialty fellowships in their areas of focus. They are trusted to care for Central Florida’s elite athletes, as the official medical provider for Orlando City and Orlando Pride soccer, University of Central Florida and Orlando Ballet.

4 FLORIDA MD - MARCH/APRIL 2023

COVER STORY They will provide that same level of care to all of their patients.

PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

Same day appointments will be available in the Orlando Health Jewett Orthopedic Institute’s newest walk-in center at the downtown complex.

“We’re really excited to offer walk-in orthopedic care at the downtown complex,” said Orlando Health Jewett Orthopedic Institute assistant vice president Kelsey Kiser. “This is a convenient alternative to an emergency room visit and can save patients time and money.”

Providers in the clinic are trained to assess and diagnose orthopedic injuries and concerns. Some patients may be able to leave the same day with a treatment plan and all follow-up appointments scheduled. In addition, Orlando Health Jewett Orthopedic Institute clinic locations across Central Florida will remain open with 24/7 access to scheduling online or through a call center.

The operating rooms inside the Eugene Jewett, MD Surgery Center are designed specifically for orthopedic surgeries. They are virtually connected so that residents, and physicians worldwide, have learning and collaboration opportunities.

The rehabilitation space is filled with the latest technology.

For injured athletes, a simulator for golf and soccer helps track progress and guide treatment. This is the same simulator that the REHABILITATION pros use on the PGA tour. Another game changer is the AlterG Orlando Health’s rehabilitation team has extensive experience, anti-gravity treadmill. Only about 10 percent of clinics have this numerous board certifications and top-quality scores in change technology, which allows patients to walk and run much earlier in function and efficiency. These expert therapists will collaborate in their recovery, with up to 80 percent of weight removed from with physicians daily to optimize care plans for patients. their bodies. The expert therapists use motion analysis cameras and force plates, which helps provide data on movement and balThe therapists use a variety of techniques. For example, many ance. To better assess when an athlete is ready to return to the therapists are certified in dry needling, which is the specialized field or court, Orlando Health has installed turf and hardwood use of micro needles to release muscular trigger points. This can surfaces in the physical therapy space, to match those surfaces often relieve pain within a day. used in sports.

The large rehabilitation space is surrounded by large windows with stunning

PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

views. Patients will have access to the latest technology for their exercises including sports simulators and an AlterG anti-gravity treadmill.

The entire clinic was designed around returning patients back to their functional levels, from office workers to professional athletes, and everyone in between.

EUGENE JEWETT, MD SURGERY CENTER The Eugene Jewett, MD Surgery Center is one of the largest ambulatory surgery centers in Florida with 12 operating rooms and three minor procedure rooms.

The ORs will only be used for orthopedic and spine surgeries. Due to the specialized use, the lay out is specifically designed to prevent infection.

The surgery center is embedded within the medical pavilion, a unique feature that provides all types of orthopedic services in one location. Not only will patients have easy access to the ASC with a dedicated parking garage and valet, they will also be able to receive pre-admission testing, imaging services, pharmacy services and outpatient rehabilitation at the Orlando Health Jewett Orthopedic Institute Downtown Complex.

FLORIDA MD - MARCH/APRIL 2023

5

COVER STORY Physicians helped configure the operating rooms to create the safest space for patients. A clean suite operating room ceiling system uses high-performance diffuser grilles to turn turbulent air flow into laminar flow, directing airborne particles and contaminants away from the patient and OR staff while encompassing the room in HEPA-filtered air. The operating rooms are equipped to live stream surgeries so residents and fellows can further their learning opportunities at the Orlando Health Jewett Orthopedic Institute. Physicians worldwide can access the streams for additional learning and collaboration opportunities.

The integration of video technology also provides a direct route for all intra-operative imaging to be uploaded into the patient’s electronic medical record. This allows the post-operative care team, such as physical and occupational therapists, the ability to review the anatomy and repair. That information helps customize post-operative therapy to achieve the most successful outcomes.

PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

In the Eugene Jewett, MD Surgery Center nano-suites, the state-of-the-art NanoScope operative arthroscopy system uses high definition, chip-on-tip image sensor technology to provide surgeons with a needle-sized, single-use camera system. The portability of the imaging system allows the surgeon to perform minimally invasive arthroscopy without the need for anesthesia.

open in August and includes an orthopedic specialty hospital, 75 inpatient rooms, plus a research and innovation center.

To prepare and alleviate any anxiety before surgery, the lobby of the hospital will feature a simulated operating room, so that patients can see the area, tools and technology that will be used during their operation.

The orthopedic specialty hospital will include 10 additional operating rooms. The 75 inpatient rooms will be “smart rooms.”

Patients can use advanced remote technology to optimize their comfort level by controlling environmental factors such as temperature and window shades. The rooms will also have large screens so that patients can view their medical information, recovery plan and watch their personal entertainment through their streaming service accounts like Netflix.

“Sometimes, simply knowing when your next medication is coming or what type of physical therapy plan is in store can be a huge relief to patients,” said Orlando Health Jewett Orthopedic Institute Allied Health and Support Services Administrator April Ernst. “We want to make sure our patients have easy access to that information with the touch of a button.”

Providing a safe and clean environment has been a top priority throughout the project. The Orlando Health Jewett Orthopedic Pre-planning and post-operative care remain at the center of Institute’s Sterile Processing department is 12,000-sq.-feet. It has positive outcomes for all same-day surgeries. Patients can aca best in class clean-to-dirty-to-clean flow. The process begins cess total joint replacement education classes to prepare for their when the cart with dirty instruments leaves the OR using a dedisurgery and classes that focus on the recovery work needed after cated contaminated elevator and arrives in the decontamination surgery. area. Once the items are decontaminated, they are loaded into one of six STERIS washer disinfectors, and the carts go through ORTHOPEDIC SPECIALTY HOSPITAL separate STERIS cart washers. These are extremely high temPhase 2 of the Orlando Health Jewett Orthopedic Institute will perature machines that render the items free of microbes. On the clean side of the department, the Patients will have easy access to parking with a new garage built directly across the street from instruments are prepped, packed, and the Orlando Health Jewett Orthopedic Institute Downtown Complex. A walkway will provide direct access to the ambulatory surgery center lobby. Valet parking is also available. loaded into one of five pass through steam sterilizers or V-pro peroxide plasma sterilizers. Once the process is complete, the instruments are returned to the operating room using a dedicated clean elevator that arrives directly to the sterile core of the operating room.

When patients visit or stay at the Orlando Health Jewett Orthopedic Institute, they can expect unique dining options. Many orthopedic patients are healthy and active, so the food will match that lifestyle. All food will be made to order, with fresh meat and fish options. Patients will also be able to order room service through an app or their hospital room’s Smart TV.

BIOSKILLS LAB A research and innovation center on the seventh floor will provide a 6 FLORIDA MD - MARCH/APRIL 2023

hands-on learning environment for orthopedic surgery residents.

It includes a 10-station cadaver lab, 3D printer and 116-seat auditorium.

“We know we have physician shortages throughout the United States. If physicians could be educated at a facility of this caliber, that puts people out in the community that have access to the latest technology and the best training you can get in the Southeast,” said Dr. George Haidukewych, Orlando Health Jewett Orthopedic Institute Academic Chairman.

An institute is defined by excellence in patient care, education, and research. The Orlando Health Jewett Orthopedic Institute’s world-renowned surgeons have published hundreds of research studies, book chapters and instructional videos. They are highly sought after speakers at national and international orthopedic meetings, and many are involved in new implant development and design. This ensures that patients have unique access to cutting-edge technologies and techniques.

Orlando Health offers a comprehensive, hands-on orthopedic surgery residency program that allows each resident to gain experience in the full range of orthopedic care, from hand and upper extremity, foot, ankle and hip subspecialties, to pediatric orthopedics, spine care and sports medicine. Orlando Health’s fellowship programs in trauma, pediatric orthopedics, surgical sports medicine and primary care sports medicine allow fellows to participate in diagnosis and treatment within their area of focus. Orlando Health also offers an orthopedic physician’s assistant and nurse practitioner fellowship.

OUR HISTORY Orlando Health acquired Jewett Orthopaedic Clinic in 2019 to begin work on the Orlando Health Jewett Orthopedic Institute – named to honor Dr. Eugene Jewett.

Dr. Eugene Jewett was a Central Florida orthopedic surgeon, and founder of the Jewett Orthopaedic Clinic, whose dedication to the specialty saved hundreds of thousands of lives. When injured and bedridden patients couldn’t access orthopedic care in the 1930’s, he would bring the care to their homes. Known to drive around with an x-ray machine and a nurse, his reputation became well-known. Soon, hospitals were asking him to visit.

They assembled rooms full of orthopedic patients for Dr. Jewett to examine and treat.

His inventions include the Jewett Hip Nail and the Jewett Hyperextension Back Brace. Both devices significantly improved the outcome for orthopedic patients. The earnings he received from the pioneering devices were poured back into medicine and education for others.

Orlando Health was founded in 1918 on the heels of World War I, in the midst of the Spanish Flu epidemic that raged across the world. Orange General Hospital, as it was known then, was supported financially by community members and a dedicated group of physicians. More than 100 years later, the healthcare system is recognized around the world for Central Florida’s only pediatric and adult Level I Trauma program as well as the only

state-accredited Level II Adult Trauma Center in Pinellas County.

It is the home of the nation’s largest neonatal intensive care unit under one roof, the only system in the southeast to offer open fetal surgery to repair the most severe forms of spina bifida, the site of an Olympic athlete training facility and operator of one of the largest and highest performing clinically Captain Eugene Jewett in the Navy, 1944 integrated networks in the region. Orlando Health has pioneered life-changing medical research and its Graduate Medical Education program hosts more than 350 residents and fellows.

Orlando Health is excited to build upon these two rich histories, to create a new legacy in orthopedics. 

OUR SPECIALTY ORTHOPEDIC CENTERS Our doctors specialize in the full range of orthopedic care, including: • Bone Health • Elbow • Hip • Hand and Wrist • Shoulder • Spine • Sports Medicine • EMG/NCV • Knee • Foot and Ankle • Head (Concussion) • Trauma • Upper Extremity Program

60 COLUMBIA ST., ORLANDO, FL 32806 321-843-5851 • ORLANDOHEALTH.COM FLORIDA MD - MARCH/APRIL 2023

7

PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

COVER STORY

DERMATOLOGY

A Bloody Mess

By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII

There are scores of prescription anticoagulants out there. I have lost track of how many, but there is a boatload. You add this on to the vast number of over the counter products that also “thin” the blood such as aspirin other nonsteroidal anti-inflammatories and then throw in things like ginseng and garlic and fish oil. It would seem that just about every patient over the age of fifty is on at least one or more anticoagulant type of medicines or supplements. America is now the land of easy bleeders and this bleeding frequently affects the skin.

Talon noir - An intraepidermal hemorrhage caused by shear force trauma.

I try to remind myself as I am sopping up blood and doing continuous cautery on vessels that do not seem to want to stop bleeding, that it is all for the better good of the patient. I’m sure this debate will rage on over the years by folks much wiser than me, but in my practice, for the last several years, I typically don’t stop anticoagulants started by other physicians. I deal with the bleeding and move on.

So far, so good! No major cerebrovascular events or blood transfusions needed. Below are photographs of different skin findings you will see when people are on blood thinners and various expressions of bleeding into the skin.

Shambergs Purpura.

Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. John Meisenheimer, VII is a medical student at USF. 

8 FLORIDA MD - MARCH/APRIL 2023

PHOTO: JOHN MEISENHEIMER, VII PHOTO: JOHN MEISENHEIMER, VII

Solar purpura or sometimes called “Senile purpura”.

A blood blister following cryosurgery on a verruca.

However, sometimes medical practice is influenced by the judicial system. Courts have determined, in California anyway, that if you stop an anticoagulant even with the permission of the prescribing cardiologist, if there is a temporally related cardiovascular event, you can also be sued and lose. The justification is Bleeding into the skin following a cupping procedure. that it is much better to deal with bleeding complications of skin surgeries a hundred times over than having one major cerebrovascular or cardiovascular event. When you think about it, this does make some sense.

PHOTO: JOHN MEISENHEIMER, VII

PHOTO: JOHN MEISENHEIMER, VII

The question may arise, well, why don’t you stop the anticoagulants before procedures, and medically this would make a lot of sense on the surface. Cessation of the anticoagulants certainly would make the surgeries go smoother without having to deal with so much bleeding. I used to do this routinely when I had the blessings of the prescriber of the anticoagulant.

PHOTO: JOHN MEISENHEIMER, VII

As a Mohs surgeon doing skin cancer surgery all day long, the anticoagulant bandwagon, of course, creates what I refer to as a bloody mess. Almost all of my patients, having surgery, are of the age range where they are taking some form of anticoagulation.

When you ask a patient if they are on anything that might “thin” the blood, if it was not prescribed, the answer is usually no. You think to yourself, great, finally someone not on a blood thinner, this case will be easy peasy. When the next question asked is, are you taking aspirin or a NSAID? The invariable answer is “yes, but that’s for my heart, joints, muscle aches, etc.” Many patients are not aware that these OTC drugs “thin the blood.”

HEALTHCARE LAW

Understanding Exculpatory Clauses

By Julie A. Tyk, JD. An exculpatory clause purports to deny an injured party the right to recover damages from a person negligently causing his injury. Cain v. Banka, 932 So. 2d 575 (Fla. 5th DCA 2006).

They are disfavored in the law because they relieve one party of the obligation to use due care and shift the risk of injury to the party who is probably least equipped to take the necessary precautions to avoid injury and bear the risk of loss. Applegate v.

Cable Water Ski, L.C., 974 So. 2d 1112, 1114 (Fla. 5th DCA 2008). Such clauses are strictly construed against the party seeking to be relieved of liability. Sunny Isles Marina, Inc. v. Adulami, 706 So. 2d 920 (Fla. 3d DCA 1998). Thus, exculpatory clauses are enforceable, only where, and to the extent, that the intention to be relieved from liability is made clear and unequivocal. Tatman v. Space Coast Kennel Club, Inc., 27 So. 3d 108, 110 (Fla. 5th DCA 2009). The wording must be so clear and understandable that “an ordinary and knowledgeable person will know what he is contracting away.” Id. (quoting Gayon v. Bally’s Total Fitness Corp., 802 So. 2d 420 (Fla. 3d DCA 2001)).

The seminal Florida case on exculpatory clauses is the Florida Supreme Court case of Sanislo v. Give Kids The World, Inc., 157 So. 3d 256 (Fla. 2015). Give Kids the World, Inc. (“GKTW”) provided free vacations to seriously ill children and their families.

When applying for the vacation, the Sanislos executed a “wish request” form that contained a waiver of liability, also known as an exculpatory clause. When the parents arrived at the resort village they again signed a liability release form, also an exculpatory clause. The language of the exculpatory clause is reprinted below for reference: I/we hereby release Give Kids the World, Inc. and all of its agents, officers, directors, servants, and employees from any liability whatsoever in connection with the preparation, execution, and fulfillment of said wish, on behalf of ourselves, the above named wish child and all other participants.

The scope of this release shall include, but not be limited to, damages or losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs and physical injury of any kind....

I/we further agree to hold harmless and to release Give Kids the World, Inc. from and against any and all claims and causes of action of every kind arising from any and all physical or emotional injuries and/or damages which may happen to me/us....

Sanislo at 258-259.

While participating in a horse-drawn wagon ride, a rear pneumatic lift designed to allow those in wheelchairs to participate failed, and Ms. Sanislo was injured. The Sanislos brought suit and GKTW filed a motion for summary judgment arguing that the signed releases precluded an action for negligence. The Sanislos filed a motion for partial summary judgment against GKTW’s affirmative defense of release. The trial court granted the Sanislo’s

motion and denied GKTW’s motion.

The jury found for the Sanislos and GKTW appealed. Id. The Fifth District reversed, finding the lower court erred in denying GKTW’s motion for summary judgment because the release signed by the Sanislos was unambiguous and did not contravene public policy. It ruled the exculpatory clause barred the negligence action despite the lack of a specific reference to “negligence” or “negligent acts” in the exculpatory clause.

The Fifth District reasoned that exculpatory clauses are effective if the wording of the exculpatory clause is clear and understandable so that an ordinary and knowledgeable person would know what he or she is contracting away, and that the court had previously rejected “‘the need for express language referring to release of the defendant for “negligence” or “negligent acts” in order to render a release effective to bar a negligence action.’ ” On the public policy argument, the Court said the relative bargaining power of the parties should not be considered because it was outside of the public utility or public function context and the Sanislos were not required to request a vacation with GKTW or go on the vacation. Id. In affirming the Fifth District’s decision, the Supreme Court wrote that the conflict for the Court’s resolution was “whether an exculpatory clause is ambiguous and thus ineffective to bar a negligence action due to the absence of express language releasing a party from its own negligence or negligent acts.” Id. at 260.

The Florida Supreme Court wrote: .... we are reluctant to hold that all exculpatory clauses that are devoid of the terms “negligence” or “negligent acts” are ineffective to bar a negligence action despite otherwise clear and unambiguous language indicating an intent to be relieved from liability in such circumstances. Application of such a bright-line and rigid rule would tend to not effectuate the intent of the parties and render such contracts otherwise meaningless.

Id. at 270.

The Court found that the GKTW liability release form released GKTW and all of its agents, officers, directors, servants and employees from “any liability whatsoever in connection with the preparation, execution and fulfillment of said wish…” The release then provided that the scope of the agreement included “damages or losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs and physical injury of any kind . . . .” The Court found that the release clearly conveyed that GKTW would be released from any liability, including negligence, for damages, losses, or injuries due to transportation, food, lodging, entertainment and photographs. Id. The determination of whether an exculpatory clause is enFLORIDA MD - MARCH/APRIL 2023

9

HEALTHCARE LAW forceable will be determined by the Judge as the enforceability of a pre-injury release is a question of law. The enforceability therefore, will depend on the Judge assigned to the matter. Physicians should not assume that because a patient signed a liability release form the patient does not have a viable cause of action. Physicians should consult with an experienced attorney who can examine the facts of the case and help you determine the best path forward. The Health Care Practice Group at Pearson Doyle Mohre and Pastis, LLP is committed to assisting Clients in navigating and defending medical malpractice claims. For more information and assistance, please contact David Doyle and Julie Tyk at Pearson Doyle Mohre & Pastis, LLP.

Check out our newly redesigned website at www.floridamd.com!

10 FLORIDA MD - MARCH/APRIL 2023

Julie A. Tyk, JD, is a Partner with Pearson Doyle Mohre & Pastis, LLP. Julie concentrates her practice in medical practice defense litigation, insurance defense litigation and health care law. She has represented physicians, hospitals, ambulatory surgical centers, nurses and other health care providers across the state of Florida. She may be contacted by calling (407) 951-8523; jtyk@pdmplaw.com.. 

ORTHOPEDICS CARE

Just for kids.

Kids and teens need prompt and innovative care specifically designed for their growing bodies.

We offer family-centered, kid-friendly care right here in Central Florida. Our expert team, including board-certified and fellowship-trained physicians, uses advanced technologies to diagnose and treat an extensive range of conditions through our highly specialized pediatric orthopedics programs.

From common to rare, we treat disorders and injuries involving bones, joints, muscles and nerves at Nemours Children’s Hospital, as well as our other specialty locations in: • Downtown Orlando • Lakeland

• Lake Mary • Melbourne

• Narcoosee Road • Winter Garden

Call 407.650.7715 to refer a patient.

Well Beyond Medicine © 2021. The Nemours Foundation. ® Nemours is a registered trademark of The Nemours Foundation. J7676 (08/21)

FLORIDA MD - MARCH/APRIL 2023 11

PEDIATRICS

Pediatric Limb Length Discrepancies By: Jason Malone, DO Q: HOW COMMON ARE PEDIATRIC LIMB LENGTH DISCREPANCIES?

done for leg difference of 2-5 cm.

A: Limb length discrepancies are very common. Up to twothirds of the population have a leg length difference of less than 2 cm (0.79 inch). Luckily, most people do not have symptoms unless the difference is greater than 2 cm.

Q: HOW LONG DOES THE PROCESS TAKE?

Q: WHAT ARE CAUSES OF LIMB LENGTH DISCREPANCIES?

A: Limb length discrepancies can be categorized into two major groups: congenital and acquired.

Congenital causes range from longitudinal deficiencies such as congenital short femurs, proximal focal femoral deficiencies, tibia hemimelia, fibular hemimelia, hemihypertrophy, unilateral clubfoot, skeletal dysplasias, and hip dysplasia. Acquired causes range from idiopathic, paralytic disorders such as cerebral palsy or polio and physeal injury from trauma, infection or tumors.

Q: WHAT TECHNIQUES DO YOU USE TO TREAT THESE PATIENTS?

A: Symptomatic leg length differences less than 1 cm can be treated with a shoe insert. A difference greater than 1 cm can be addressed with nonsurgical treatment with a customized shoe lift.

However, some patients or families do not wish to use a brace or shoe insert for the rest of their life.

A: Distraction osteogenesis is a long process. After the initial surgery we wait about a week for the bony callus or regenerate to develop. We then lengthen 1 mm per day. Then the bone takes about 8-12 weeks to fully heal the regenerate. A large 5 cm lengthening can take about 100 days to fully heal.

Q: WHAT ARE THE POTENTIAL COMPLICATIONS INVOLVED?

A: Distraction osteogenesis is safe if performed and monitored by an experienced physician, but it can also be associated with multitude problems. The bones, tendons, muscles and neurovascular structures are growing faster than the body is used to growing, so patients can develop joint contractures, joint dislocations and nerve stretch. We combat this by using nighttime braces, starting physical therapy right away, and stopping the lengthening process if any major complication develops. We can also lengthen more in the future. You also have your standard complication that can happen with any orthopedic procedure such as infection, nonunion, malunion or hardware failure.

Leg differences can be treated with a shortening procedure on the long side or a lengthening procedure on the short side or a combination of the two. Shortening procedures are smaller surgeries that are quicker to recover from but do lead shorter stature. Lengthening procedures are classically done for differences greater than 5 cm but many deformity specialists are now treating smaller leg length differences down to 3 cm in skeletally mature patients.

An epiphysiodesis can also have its complications such as fracture at the physis, continue growth, angular deformity if the entire growth plate is not fully removed and continues to grow, not timing the surgery right and not achieving the desired correction or even overcorrecting and needing to perform an epiphysiodesis on the contralateral side.

Q: HOW DOES THE PROCESS WORK?

A: A child should see a pediatric orthopedic surgeon specialized in deformity correction when they have a congenital leg length difference, when they have a physeal injury, or an idiopathic leg length difference that is symptomatic or over 2 cm.

A: Limb Lengthening procedures were first described by Dr. Gavriil Ilizarov in the 1950s. He called the process distraction osteogenesis. The process entails making a fracture in a bone, having the patient rest for 5-7 days, then distracting the bone ends about 1 mm per day. The bones can be distracted with an external fixator, a mechanical intramedullary nail, and soon with an expanding plate. We can safely lengthen a bone about 5 cm per treatment.

External fixators are better for legs that have an associated large deformity or children with open growth plates. Intramedullary nails are better tolerated but can only be placed in the femur of children at least 8 years old once the growth plate is closed in the tibia. The new lengthening plates that should be out in the summer of 2021 will allow us to lengthen internally even when a child has an open growth plate.

Shortening procedures usually are done in growing children.

This is done through a timed epiphysiodesis. I prefer to perform a percutaneous epiphysiodesis as it leaves small scars and is associated with less complications than other techniques. This is 12 FLORIDA MD - MARCH/APRIL 2023

Q: WHEN SHOULD A CHILD SEE A SPECIALIST TO ADDRESS THE DISCREPANCY?

Q: ARE YOU CURRENTLY DOING ANY RESEARCH IN THE FIELD?

A: I just finished a research paper looking through a nationwide database from 1997-2016 on trends in femoral lengthenings in pediatric patients. What we found are that most of the surgeries are performed in large urban teaching hospitals. The South does more lengthenings than any other region in the country. The surgery has become safer over the years with shorter hospital stays but like most of medicine, the costs have risen substantially through the years. We currently have the paper submit for publication.

Jason Malone, DO, is a fellowship-trained pediatric orthopedic surgeon at Nemours Children’s Health who specializes in treating limb length discrepancies and deformities. Call (407) 650-7715 for more information. 

PEDIATRICS

9-year-old boy had a physeal injury to his left tibia. He sustained a 5 cm leg length difference with a flexion deformity of his knee. He had a projected leg length difference 9.6 cm.

He was treated with a hexapod external fixator to lengthen his leg 5 cm and correct his deformity.

16-year-old boy with an idiopathic 4 cm leg length difference, right genu valgum and an osteochondroma.

He was treated with a lengthening intramedullary nail, acute correction of his knee dormity and excision of his osteochondroma.

The tibia is now healed right before the external fixator is removed.

The femur is now healed right before the nail was removed.

FLORIDA MD - MARCH/APRIL 2023 13

PULMONARY AND SLEEP DISORDERS

Pulmonary Rehabilitation

By Daniel T. Layish, MD, FACP, FCCP, FAASM Pulmonary rehabilitation can benefit patients with a wide variety of lung diseases including COPD, pulmonary fibrosis, cystic fibrosis, and sarcoidosis (among other chronic respiratory illnesses). Pulmonary rehabilitation does not replace standard medical and/or surgical treatments for these lung diseases. Rather, it supplements and complements standard therapy.

Patients with COPD (and other chronic lung diseases) develop shortness of breath with activity. This leads to the tendency to avoid activity, which in turn leads to deconditioning. It is felt that one of the main benefits of pulmonary rehabilitation is to break the cycle of deconditioning. Pulmonary rehabilitation programs typically include two or three outpatient sessions per week for 10 to 12 weeks. Typically, a pulmonary rehab program will include aerobic exercise, strength training, patient education in management of lung disease - including nutrition, energy conservation, medication compliance, bronchial hygiene, and breathing strategies. The component of group support is also felt to be a significant contributor to the success of these programs. The group support motivates the patient to attend the pulmonary rehab sessions. It also allows the patient to realize that there are other people suffering from chronic respiratory illness and to see how they are able to overcome these obstacles. Pulmonary rehabilitation is considered to be critical both before and after lung transplantation. Occasionally, a patient will have such a significant functional and symptomatic improvement after pulmonary rehab that transplant can be delayed.

Pulmonary rehabilitation programs are typically multidisciplinary in nature and may include a respiratory therapist, registered nurse, exercise physiologist, nutritionist, physical and/ or occupational therapists. The staff is trained to encourage the patient’s self management and coach them to adopt healthier habits through lifestyle modification. To enroll in a pulmonary rehabilitation program requires a medical referral. Pulmonary rehabilitation is covered by most third party payors. Pulmonary rehabilitation is appropriate for any stable patient with a chronic lung disease who is disabled by respiratory symptoms.

The pulmonary rehab program should involve assessment of the patient’s individual needs and creation of a treatment plan that incorporates realistic goals tailored to each patient. Evidence based analysis consistently reveals improvement in health related quality of life after pulmonary rehabilitation as well as improved exercise tolerance. Pulmonary rehabilitation has been shown to improve the symptom of dyspnea and increase the ability to perform activities of daily living. Pulmonary rehabilitation has also been shown to reduce health care utilization (including frequency of hospitalization) and decreases length of stay (when hospitalization is required). Pulmonary rehabilitation has not been demonstrated to improve survival.

The benefit from a pulmonary rehabilitation program may decline over time if the individual does not maintain their con14 FLORIDA MD - MARCH/APRIL 2023

ditioning. Some pulmonary rehabilitation programs will therefore include a “graduate” or maintenance program after the patient finishes the initial program.

Patients who develop shortness of breath often become anxious which in turn exacerbates the sensation of dyspnea and this can become a vicious cycle. Pulmonary rehabilitation can be very helpful in addressing this problem. Sometimes pulmonary rehabilitation will require supplemental oxygen with exercise.

Although the strongest evidence regarding pulmonary rehabilitation programs is in the setting of COPD, it has been shown to be beneficial in a variety of disease states. Pulmonary rehabilitation has been shown to be a cost effective tool in the fight against chronic lung disease. It is currently felt to be underutilized.

Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in 1990. He then completed an Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical Care/Sleep Medicine Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He serves as Co-director of the Adult Cystic Fibrosis Program in Orlando. He may be contacted at 407841-1100 or by visiting www.cfpulmonary.com. 

Sea Notes Photography Donald Rauhofer – Photographer Head Shots • Brochures • Meetings Events • Portraits • Arcitectural

4O7-417-74OO

THE BEST EEG CLINICAL CARE

FROM THE COMFORT OF HOME 01 Convenience & Comfort

In-home testing puts the mind at ease, leading to a more accurate picture of neurological activity.

NeuLine Health is a neurodiagnostic services provider that performs convenient, at-home Ambulatory EEG testing for patients with neurological-related medical conditions.

We are dedicated to serving qualified healthcare providers and their patients with best-in-class neurodiagnostic testing, nationwide.

02 Affordability

Testing through NeuLine Health typically costs 3X less than inpatient care.

03 Rapid Results

Scheduling with NeuLine Health is fast and convenient, leading to faster answers on the next steps in your treatment.

Visit neulinehealth.com/providers or call (844) 212-5321 to learn more.

FLORIDA MD - MARCH/APRIL 2023 15

When The Tremor Isn’t Essential –

Parkinson’s Disease: One of the Most Commonly Misdiagnosed Neurological Conditions

By Jaivir S. Rathore, M.D, F.A.E.S & Idha Sood, M.B;B.S

A COMPREHENSIVE ARTICLE, ON THE OCCASION OF WORLD PARKINSON’S DAY • APRIL 11, 2023 WHAT IS PARKINSON’S DISEASE? Parkinson’s disease (PD) is the second-most common neurodegenerative disease after Alzheimer’s dementia. More than 10 million people worldwide and nearly one million people in the U.S. are living with PD. This number is expected to rise to 1.2 million by 2030. Nearly 90,000 people in the U.S. are diagnosed with PD each year. The incidence of PD increases with age, but an estimated four percent of people with PD are diagnosed before age 50. Men are 1.5 times more likely to have PD than women. Within the US; Florida has the second highest population of people living with PD. It is a slowly progressive disorder which often first presents with a resting hand tremor. The patient can then develop other cardinal features of bradykinesia, rigidity and postural instability.

Autonomic symptoms like constipation, poor sense of smell, excess salivation due to poor swallowing can be present years before the patient develops the classic PD symptoms. In some patients there can be signs of cognitive decline which could be part of “Parkinson’s Plus” or Parkinson’s dementia.

WHAT CAUSES PARKINSON’S DISEASE? PD results from loss of dopaminergic neurons in the pars compacta of substantia nigra of basal ganglia which is responsible for subcortical control of motor activity. In most cases the exact cause is unknown (Idiopathic Parkinson’s Syndrome, IPS), up to 15% cases may have genetic components, most common being LRRK2, GBA and PRKN (associated with young onset PD). In some cases it has also been linked to exposure to certain pesticides, herbicides, and industrial chemicals. One such compound called MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) accumulates in the mitochondria and generates free radicals, which can cause damage to basal ganglia and hence lead to PD. Latest research is also suggestive of alpha synuclein aggregation playing a role in the pathogenesis of PD. The earliest histopathological changes are hence seen in the myenteric plexus of the gastrointestinal tract, which then progresses to involve the dorsal motor nucleus of the vagus nerve and sleep centers in the ponto-medullary brainstem.

Many known figures in the world history have been affected by Parkinson’s disease including Pope John Paul II, Adolf Hitler, Mao Zedong, Michael J Fox and notably world heavyweight boxing champion Muhammad Ali, in his case repeated hits to his head is considered a risk factor to cause “dementia pugilistica” a neurode generative condition with Alzheimer’s like dementia. Neurode generation is a serious issue for boxing or for any traumatic brain injury for that matter.

16 FLORIDA MD - MARCH/APRIL 2023

WHAT ARE THE EARLY SIGNS OF PARKINSON’S DISEASE? Patients typically have constipation, poor sense of smell and REM sleep disorder preceding the motor symptoms by around 10-15 years. Patients most commonly present with the earliest symptom of tremor. The tremor is usually present at rest and sometimes has classic pin rolling features involving the thumb and the index finger; it can disappear for some time while doing a task but returns when the patient is distracted. In cases where PD is not tremor dominant, patients usually present with the cardinal features of “overall slowness” or bradykinesia, mask facies, muffled speech (hypophonia), small handwriting (micrographia) etc. Patients can take a long time to do their usual daily activities and walk slowly. When prompted about mood or sleep issues, patients might elaborate on feeling depressed and can give a history of movements in their sleep, likely REM sleep disorder. Other autonomic features that a patient of PD might have include urinary retention, erectile dysfunction and orthostatic hypotension. Patients with advanced disease can also present with memory decline due to the neurodegenerative changes of the brain.

On examination, patients have the characteristic cog-wheel rigidity which can be elicited by slow rotatory movements of their wrists. Patients can appear to be stiff, they have shortened stride while walking and arm swing is typically reduced asymmetrically. They walk with a stooped posture and have to take multiple short steps to turn around. On pulling them back suddenly, called the posterior pull test, patients take a lot of steps to catch themselves or may even fall.

HOW DOES PARKINSON’S DISEASE PROGRESS? In classic PD cases, the patient has tremor of one hand in stage 1. This can progress to the other hand in stage 2. Stage 3 is characterized by mild balance problems, which can worsen causing falls in stage 4 needing cane or a walker to walk and if it continues to worsen, in stage 5 patients can be wheelchair or bed bound. Not all patients progress to stage 5 and brain imaging such as (Dopamine Transporter, DaT) scan is not usually a good prognostication tool.

WHAT MIMICS PARKINSON’S DISEASE? The PD tremor is most commonly mistaken for an essential

tremor and it remains refractory of usual treatment of propranolol, primidone etc. In such situations, emphasis should be put on looking out for other clinical features of PD like bradykinesia and gait disturbances.

In clinically uncertain cases nuclear imaging DAT-SPECT scan may be helpful, however routine use of this test should be discouraged. A clear clinical improvement after levodopa treatment provides the best confirmation of PD.

Progressive supranuclear palsy (PSP) can have similar features of bradykinesia, rigidity and gait disturbances but patients may also have vertical gaze paralysis and falling en-block while sitting which is not a feature of PD and MRI Brain of PSP patient may show midbrain atrophy which is described as “Hummingbird” sign.

HOW IS PARKINSON’S DISEASE TREATED?

Patients of Lewy Body Dementia (LBD) have many features of Parkinson’s but those symptoms usually tend to occur after dementia symptoms. In contrast dementia is progressively developed later in the course of disease in PD patients due to overall neurodegeneration. In addition, LBD patients have very vivid visual hallucinations along with wide mood fluctuation which are not a feature of PD, however PD dementia patients may get hallucination or psychosis which is treated with pimavanserin. Ischemic or hemorrhagic stroke, mass lesions, hydrocephalus and Wilson’s disease can be excluded using imaging techniques such as MRI brain.

HOW IS PARKINSON’S DISEASE DIAGNOSED?

IMAGE COURTESY DTSCH ARZTEBL INT 2019 BUCHERT, R ET AL.

The diagnosis of PD is primarily a clinical one. A comprehensive examination and proper staging of PD can be done using Unified Parkinson’s Disease Rating Scale (UPDRS) which is a gold standard tool to measure not only the severity and progression of PD but also helpful in monitoring the response to medications. While evaluating the patient it is also imperative to go over their list of medications to exclude the possibility of drug-induced PD. Traditional antipsychotic medications are most implicated in such a condition.

There is no cure for PD at this time, however since the pathogenesis of PD involves loss of dopaminergic neurons, the primary mode of treatment is replenishing the dopamine levels with medications such as levodopa with carbidopa, which may also be used in combination with other classes of medications including Dopamine Agonists, COMT Inhibitors, MAO-B Inhibitors, and Anticholinergic agents. Treatment is individualized to the patient and adjusted over time based on symptoms, side effects and tolerability. Dopamine agonists like pramipexole, or ropinirole can be used in younger patients with the advantage of lesser side effects. If a patient primarily has tremor only, amantadine or anticholinergics may be used. In advanced stages of PD, patients may have psychosis with visual or auditory hallucinations and delusions. Pimavanserin, a serotonin 5-HT2 receptor antagonist is the only FDF approved treatment for psychosis associated with PD. Most PD medications provide good improvement in symptoms for the first 3 to 6 years, but with the natural progression of the disease, results can decline with time. Levodopa-Carbidopa can have the “on-off” phenomenon where symptoms may worsen during the “off” periods. Apomorphine, a dopamine agonist, is the only FDA approved medication which can be used for symptom control during the off periods.

Deep Brain Stimulation (DBS) is a promising and underutilized advanced treatment for people who experience disabling tremors, wearing-off spells, and medication induced dyskinesias.

Typical Dopamine Transporter Ligands Single Photon Emission Tomography (DaT-SPECT) scan findings in patients with Idiopathic Parkinson’s Syndrome (IPS) showing reduced striatal DAT availability compared with a normal finding. The reduction is often left/right asymmetrical, usually more pronounced in the hemisphere contralateral to the clinically dominant side. The posterior “tail” of the putamen is almost always most strongly affected. The motor symptoms of IPS manifest only after a DAT loss of about 50% in the putamen. The atypical neurodegen erative parkinsonian syndromes, especially Progressive Supranuclear Palsy (PSP) and Multiple System Atrophy (MSA) of the parkinsonian type show similar patterns of findings on DAT-SPECT as IPS.

PD being a multi system disease requires a multi system ap proach. Patients can benefit a lot with physical therapy, like LS VT-BIG (Lee Silverman Voice Treatment), which encompasses physical therapy to improve their gait and balance coupled with speech therapy to address the hypophonia which can be pres ent.

Patients should be encouraged to have an active lifestyle.

Continued on page 20 FLORIDA MD - MARCH/APRIL 2023 17

ORTHOPEDICS

Your Patient Is Not Happy with Their Knee or Hip Replacement. What’s Next?

By George J. Haidukewych, MD According to the Agency for Healthcare Research and Quality, more than 790,000 knee and 450,000 hip replacements are performed in the United States each year. While these numbers declined somewhat over the past year due to obvious reasons and events related to the pandemic, experts project a significant upward trend in medically indicated joint replacement surgeries over the next 10 years.

More than 85-90 percent of patients who undergo total knee or hip arthroplasty (TKA/THA) surgery experience a favorable outcome, with a decrease in pain, an increase in mobility and an overall improved quality of life. And with advances in technology, patients can expect their replacement joint to function well for 20 years or longer. But not all joint replacement surgeries are successful. Complications and failures can occur, and patients who expected dramatic pain relief and function after a knee or hip replacement may present with persistent pain, as well as considerable frustration and unhappiness.

About a third of patients will still have some aches and pains following knee or hip replacement. Early problems can be due to technical factors involving the surgery, inadequate rehab, or more serious problems such as infection or loosening. Problems can also occur years after surgery as the ceramics and plastics start to wear through. A joint replacement that had previously been functioning well for several years can suddenly start hurting or swelling.

The most common complaints following TKA include swelling, activity-related pain and mechanical symptoms, like a crunching behind the kneecap and even clicking when the patient walks.

With THA, common painful symptoms include persistent pain around the tendon or bursa on the side of the hip.

WHAT DO YOU DO IF YOUR PATIENT EXPERIENCES PERSISTENT PAIN AFTER JOINT REPLACEMENT SURGERY? Sorting out what is a normal discomfort for a prosthetic joint and what is a more serious problem is not always straightforward.

What may seem like a minor ache or pain could be a sign of a more serious underlying problem. Problems such as instability or loosening of the knee or hip, or even more unusual problems like corrosion or metal sensitivity, can be easily misdiagnosed; ruling out infection and instability is critical.

The optimal plan of care for those patients who continue to experience ongoing joint pain after TKA or THA is an evaluation referral with an orthopedic specialist. Specialized tertiary referral centers like Orlando Health Jewett Orthopedic Institute offer expert specialist care and advanced technology, including leadingedge imaging, such as MRI scanning with metal artifacts suppression, to diagnose reasons for persistent symptoms after a knee or hip replacement.

18 FLORIDA MD - MARCH/APRIL 2023

Sometimes patients have unrealistic expectations of their replacement, because of what they’ve been told or seen on TV or social media.

Expecting the joint to be normal versus artificial is a common source of dissatisfaction. They may not follow proper rehab or activity levels. These patients require a comprehensive evaluation of their overall fitness level, including other joints like the shoulders and ankles. Patients need to focus on total body fitness and understand what a replacement joint can and cannot do.

An overall aging population, a rise in the prevalence of risk factors such as obesity, and the popularity of maintaining active lifestyles not only contribute to the increasing number of joint replacement surgeries, but also the inevitable consequential increase in complications or failed joint replacements. We also have seen an increasing number of joint replacements in a younger patient population whose active lifestyles place added stress and wear on their original and replacement joints. With normal use and activity, every joint replacement implant begins to wear over time, and excessive activity or weight may increase the rate of this normal wear, causing the replacement joint to loosen and become painful.

Evaluation by an orthopedic specialist may determine that a painful knee or hip replacement does need any further surgical intervention. It may simply be something that indicates additional physical therapy, weight loss or activity modification. But there is an increasing number of patients who will require a joint replacement revision (redo).

WHEN IS REVISION SURGERY NECESSARY? Revision, or redo, surgery is a complex procedure that involves removing and replacing the original joint implant, usually due to a complication from the initial replacement.

Overall, complication rates following TKA or THA surgery are low. Serious complications, such as a joint infection, occur in fewer than 1-2 percent of patients. Instability can occur in 2-3 percent of knee replacements, and 2-3 percent of hip replacements can have a dislocation or similar problem. These percentages are small, but given the large number of surgeries performed, it adds up to a significant number of people experiencing undue discomfort and pain.

Typically, more women than men undergo knee replacement, with hip replacements being about even between men and women. Overall, men place more wear on replacement joints than women, due both to more body weight and slightly more activity, resulting in a slightly higher need for revision surgery.

Data from Medicare shows that the average rate of revision surgery within 90 days is 0.2 percent but increases to 3.7 percent

ORTHOPEDICS within 18 months. These are usually due to infection or mechanical complications of the implant. While surgical techniques and implant designs and materials continue to advance, implant surfaces can wear down and the components can loosen over time. Research suggests that long-term wear and loosening affects 6 percent of people after 5 years and 12-15 percent after 10 years.

Only a handful of centers in Florida specialize in diagnosing and treating conditions associated with problematic joint replacements.

Specialists with the Orlando Health Jewett Orthopedic Institute perform hundreds of successful revisions of knee and hip replacements every year for patients throughout Florida and the Southeast.

These complex, long procedures can be challenging and require multidisciplinary and subspecialty care, including infectious disease experts and plastic surgeons, as well as advanced surgical, intensive care, recovery and rehabilitation facilities that provide a higher level of care. Backed by all the resources of the Orlando Health system, Orlando Health Jewett Orthopedic Institute offers this advanced level of care. And, expected to be completed in 2023, a new, state-of-the-art orthopedic complex on Orlando Health’s downtown Orlando campus will usher in the next generation of orthopedic care.

Ultimately, the basic message for your patients is “Don’t give up hope!” An orthopedic surgeon who specializes in complex knee and hip revision work can provide a comprehensive evaluation to determine how to best correct a persistent joint replacement problem.

Internationally recognized for joint replacement surgery and trauma, George J. Haidukewych, MD, serves as Orlando Health’s director of orthopedic trauma and chief of complex joint replacement, practicing at the Orlando Health Jewett Or-

FloridaMDMagazine.com

thopedic Institute. Dr. Haiduke-

Your Medical Business Resource

wych specializes in total hip and total knee replacements as well as orthopedic trauma. He brings

Practice Management Advice

extensive experience in the man-

Financial Information

agement of failed and infected total hip and total knee replacements and in reconstruction of

Pod Cast Interviews with Specialists and Professionals

the joints after trauma. Up to half of his practice is dedicated to solving these challenging prob-

Medical Classifieds

lems from around the Southeast.

Back Issues with Informative and Interesting Stories

Dr. Haidukewych completed his residency training at the Mayo Clinic in Rochester, Minnesota, as well as a fellowship at Flori-

For Information Please Email: info@floridamdmagazine.com or call 407.417.7400

da Orthopaedic Institute in the Tampa Bay area.



FL MD Full Pg Ad.indd 1

4/30/10 4:16:48 PM

FLORIDA MD - MARCH/APRIL 2023 19

Continued from page 17

Other features of PD including depression, constipation. REM sleep disorders should also be managed concomitantly.

In long-standing or medically refractory cases of at least 4 years of PD, Deep Brain Stimulation (DBS) of the subthalamic nucleus (STN) or globus pallidus interna (GPI) is a great option to provide relief with disabling symptoms. In summary, early accurate diagnosis by a neurologist experienced in PD along with a multidisciplinary approach should be used for improving the symptoms and quality of life of PD patients.

Dr. Jaivir Rathore, A triple board-certified top-rated neurologist trained at the Johns Hopkins and the Cleveland Clinic, Harvard University journal published neuroscientist and the Medical Director of Falcon Advanced Neurology & Epilepsy Freedom Center (FANEFC) in Orlando FL with additional clinics serving the largest retirement community of the world in The Villages FL provides comprehensive neurology care including movement disorders such as Parkinson’s disease. FANEFC is “Care Connected” with the Mayo Clinic, Jacksonville FL for surgical cases including DBS for PD. 

FloridaMD is the perfect partner to help you increase referrals to your specialty practice.

For Information Please

Email: info@floridamd.com Text or call 407.417.7400 20 FLORIDA MD - MARCH/APRIL 2023

2023

EDITORIAL CALENDAR

Florida MD is a monthly medical/business digital magazine for physicians..

Florida MD is emailed directly to healthcare providers in Orange, Seminole, Flagler, Volusia, Osceola, Polk, Brevard, Lake and Indian River counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD. It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

JANUARY –

Digestive Disorders Diabetes

FEBRUARY –

Cardiology Heart Disease & Stroke

MARCH –

Orthopaedics Men’s Health

APRIL –

Surgery Scoliosis

MAY –

Women’s Health Advances in Cosmetic Surgery

JUNE –

Allergies Pulmonary & Sleep Disorders

JULY –

Neurology / Neuroscience Advances in Rehabilitation

AUGUST –

Sports Medicine Robotic Surgery

SEPTEMBER – Pediatrics & Advances in NICUs Autism OCTOBER –

Cancer Dermatology

NOVEMBER – Urology Geriatric Medicine / Glaucoma DECEMBER – Pain Management Occupational Therapy

Please call 407.417.7400 for additional materials or information.

FLORIDA MD - MARCH/APRIL 2023 21

GIFT CERTIFICATES ARE AVAILABLE

The Natural Way to Solve your Allergy, Sinus and Respiratory Discomfort.

ANTI-BACTERIAL | SIDE EFFECT FREE | ANTI-INFLAMMATORY

Relieve Symptoms of: • Acne • Allergies • Asthma • Cold & Flu • Cystic Fibrosis • Dermatitis • Ear Infections 100% NATURAL • Eczema TREATMENT • Sinusitis ::

DRUG FREE

FUSION OF

SCIENCE & NATURE

Kerri and Clay: “My son’s allergy medicines were causing terrible side effects. Now that we have been coming to The Salt Room we have been able to control his symptoms with salt therapy.”

Jessica L.: “My son looked and felt better after just one session. His cough wasn’t as bad. I felt he could breathe so much better.”

Joseph Cannizzaro, MD: “I have been recommending The Salt Room for years. It has helped my patients with respiratory nuisances and skin problems, reducing symptoms while we address the root cause to improve their long-term quality of life.”

407.862.1163 l 357 Wekiva Springs Rd., Longwood l www.SaltRoomLongwood.com

................

18

Located inside Cannizzaro Integrative Pediatric Center. Offering relief to all ages.