J U LY 2 0 1 0
Carolina Vein Center Treating Tired, Achy, Heavy, Swollen Legs
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
Also in this Issue Get Back in the Game with ACL Surgery Tommy John Surgery Has Major League Success
Beyond Imagination. Working in partnership with physicians for over 50 years to bring the benefits of biomedical technology to patients around the world.
A. One heart at a time. World-renowned arrhythmia (abnormal heart rhythm) specialist James Daubert, MD, is the leader of Duke’s electrophysiology program.
Q. How do you get to be one of the world’s best heart centers? Heart-rhythm specialist James Daubert, MD,
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Durham
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Contents
COVER STORY
6 Carolina Vein Center
PHOTO BY JIM SHAW
Advancing care and awareness
FEATURES
14
Sports Medicine
J U N E 2 0 1 0 V O L U M E 1 I S S U E 6
19
Susan G. Komen for the Cure
Tommy John Surgery Has Major League Success
A Charity You Can Trust
Surgery is increasingly the treatment of choice for many sports injuries, including one to restore stability in elbows, so pitchers can go on to play another day.
The annual race in Raleigh drew 25,000 and raised nearly $2 million. The organization and it’s local affiliates are among the most wellrespected charities in the world.
DEPARTMENTS 13 Insurance It’s Hurricane Season! Is Your Office Ready for Disaster?
16 Neurosurgery Effectiveness of New Approaches in Cervical Spine Surgery Varies
20 Business Management Marketing is Present in a Successful Practice
22 Sports Medicine Athletes Get Back in the Game with ACL Surgery
24 News Welcome to the Area, CME Courses, Upcoming Events and Updated Websites
25 Cardiology Cary Cardiology Expands Services with Addition of Electrophysiologist
26 Sports Medicine New Developments Advance Rotator Cuff Surgery
28 Radiology Imaging’s Role Increases as Arthritis Diagnosis and Treatment Advances
30 Women’s Health New Drug and IUD Offer Improved Treatment Options for Heavy Bleeding
32 Pain Management COVER PHOTO: Lindy McHutchison, M.D., specializes in the emerging medical field of phlebology, the diagnosis and treatment of vein disorders: Photo by Jim Shaw. Varicose vein image: ©www.istockphoto.com/audietaylor
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The Triangle Physician
Headache Specialty Clinics Take Control of Chronic Migraine
From the Editor
American Heroes On Independence Day, we unleash a cacophony of skyrockets in celebration of this nation’s founding. It is an equally solemn occasion, when we take pause to think about the cost of sustaining our hard-won freedom. Great gratitude goes to those who work tirelessly to treat traumatic physical and emotional wartime injuries on the frontline and to those stateside working in countless ways to promote healing and lend support. All of you are to be saluted for your service to our troops. The cover story of The Triangle Physician this month features Carolina Vein Center, led by Dr. Lindy McHutchison. She explains that the focus of her practice is to liberate patients from pain and discomfort. She also discusses the significance of phlebology’s recognition by the American Medical Association and the America Osteopathic Association in 2007. Acceptance of phlebology as a vital, legitimate medical field has led to increased willingness by insurance companies to provide coverage, awareness among physicians of advances in treating venous disease and patient benefit. Unlike in the past, medical options today are minimally invasive and result in quick-healing, aesthetic results. Also in this issue, sports medicine specialists Douglas Gollehon and Mark Galland write about surgery to treat injuries of the anterior cruciate ligament and the ulnar collateral ligament, respectively. Both injuries commonly occur on another so-called battleground – the ball field. Once athletes would have been permanently sidelined. Now they have a greater chance of getting back in the game to fight for the home team. Another orthopedic surgeon, Dr. Claude Moorman advises on breakthrough developments in the treatment of rotator cuff injuries, often the result of competitive and recreational athletics, as well. Cary Cardiology announces the addition of electrophysiologist Pavlo Netrebko in its arsenal against heart disease. Dr. Anne Calhoun discusses the value of headache specialty clinics in the struggle against migraine. Dr. Andrea Lukes reviews new treatments for relief of the seemingly unrelenting condition of heavy menstrual bleeding. Neurosurgeon Dennis Bullard helps clarify the benefits of the latest spine surgery, and radiologist Charles Pope describes the expanded uses of magnetic resonance imaging in the diagnosis and treatment of arthritis. Read on about what makes Susan G. Komen for the Cure such a winning brand in the war against breast cancer. Mike Riddick tells how to batten the office hatches in the event of a hurricane and John Reidelbach gives a heads up on medical practice branding. As branding strategies go, your presence on the pages of The Triangle Physician will reach more than 8,000 physicians, nurse practitioners and hospital staff. That’s a lot of bang for the buck. Our deepest respect and gratitude for all you do.
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
Editor Heidi Ketler, APR
heidi@trianglephysician.com
Contributing Editors Anne H. Calhoun, M.D.; Douglas L. Gollehon, M.D.; Heidi Ketler; Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G; Pavlo I. Netrebko, M.D.; John Reidelbach; and Mike Riddick Photography Jim Shaw Photography jimshawphoto@earthlink.net Creative Director Joseph Dally
jdally@newdallydesign.com
Advertising Sales Carolyn Walters carolyn@trianglephysician.com News and Columns Please send to info@trianglephysician.com
The Triangle Physician is published by New Dally Design 9611 Ravenscroft Ln NW, Concrd, NC 28027
Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401 Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinion expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. However, The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser.
Heidi Ketler Editor
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No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.
On the Cover
Carolina Vein Center
By Heidi Ketler
Liberates Patients from Pain
“Of all the pleasures life can gain, ’tis not in treasures but relief from pain.” – Anonymous. PHOTO BY JIM SHAW
p Evalution of venous disease involves thorough examination of the legs.
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PHOTO BY JIM SHAW
Venous disease can affect legs of all shapes and sizes.
B
rinton Strode has never had better feeling and looking legs. Gone are the varicose veins that were unsightly at best. “I could model for AARP,” jokes the 60-year-old retired senior vice president of operations for Oxford University Press and Apex resident. More importantly, the absence of varicose veins – after treatments by Lindy McHutchison, M.D., of the Carolina Vein Center – means less tired, achy, heavy, swollen legs and for Mr. Strode a reduced risk of a serious health concern, deep vein thrombosis (DVT).
For further treatment, Mr. Strode was referred to a hematologist, specializing in vascular diseases at Rex Hospital. The hematologist determined a broken varicose vein contributed to the DVT. He prescribed a blood thinner and compression stockings. Mr. Strode also underwent genetic testing for DVT predisposition. Since only one marker was found, the internist determined Mr. Strode’s chances of a recurrent DVT would be reduced with treatment of his varicose veins in both legs.
Like his mother, Mr. Strode believed he was destined to live with varicose veins, a condition that manifested when he was a teenager. “I am not a person who cares if I had good-looking legs or not,” says Mr. Strode.
The absence of varicose veins means less tired, achy, heavy, swollen legs and can reduce the risk of deep vein thrombosis.
Almost 40 years later, Mr. Strode’s symptomatic, bulging varicose veins may have contributed to a DVT. Last September, his right leg became painful and swollen. Evaluation by his primary care physician revealed a blood clot deep in his leg.
Upon referral to Carolina Vein Center, Dr. McHutchison evaluated Mr. Strode’s varicose veins and verified that his DVT was no longer present. Her staff worked with his insurance company to assure coverage for the recommended treatments: ambulatory PHOTO BY JIM SHAW
p Using a vein light helps locate “feeder veins” and varicose veins just under the skin. JULY 2010
7
PHOTO BY JIM SHAW
p A carefully performed duplex ultrasound maps the veins and checks the direction of blood flow in the veins.
phlebectomy to remove superficial bulging varicose veins, endovenous laser ablation to close the leg’s saphenous veins and sclerotherapy injections for the remaining diseased veins. The outpatient procedures in Mr. Strode’s treatment plan were deemed medically necessary, he satisfied the insurance company’s requirement to wear compression stockings for three to six months prior to definitive treatment and once approval from his insurance company was granted, his treatments began.
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In mid-March, Dr. McHutchison began the first of four procedures on Mr. Strode’s legs over the course of four weeks. Each was performed under local anesthesia at Carolina Vein Center. Throughout his treatment, Dr. McHutchison was in consultation with Mr. Strode’s primary physicians. MEDICAL PROBLEM IS MORE THAN SKIN DEEP It is estimated that more than 80 million Americans suffer from some form of venous disorder. More than half have a family history of venous disorders. Since females usually have multiple risk factors, venous disease affects
about 75 percent more women than men. The function of veins in the circulatory system is to pump oxygen-poor blood back to the heart. These thin-walled structures contain a series of one-way valves that keep the blood flowing antegrade (toward the heart). Muscle contractions in leg muscles propel the blood forward. When the muscles relax, normal (competent) valves snap shut, preventing blood from flowing backward, or retrograde (toward the feet). When the vein walls and/or valves are weak and damaged, the vein becomes
Before
After
p A 45-year-old woman with chronic venous disease before and after bilateral endovenous laser ablation and sclerotherapy.
incompetent and blood is allowed to flow retrograde causing venous congestion and pooling. The condition called venous reflux creates unusually high pressure buildup in the veins, resulting in stretching and twisting of leg veins, increased swelling and more valve incompetence. The sluggish blood flow creates the potential for blood clot formation. This is called venous insufficiency and is often evident at the surface of the skin as varicose and spider veins. Over time, this phenomena contributes to chronic venous insufficiency. The most common causes of defective vein valves are an inherited (genetic) weakness of the vein wall. Pregnancies and hormones, such as progesterone, that relax the muscle of the vein wall, obesity, hormone replacement therapy, as well as occupations that require a standing position, are aggravating factors. Besides cosmetic complaints, varicose veins can cause leg aching, pain, heaviness,
fatigue, ankle swelling, muscle cramping, restlessness, itching and burning, especially at the end of the day. After years of reflux, the pressure in the veins actually increases and may cause skin changes, pigmentation and in severe cases venous ulcer.
The best news for those suffering from venous disease is that treatment has improved with the evolution of phlebology in the past two decades. PHLEBOLOGY EMERGES WITH MEDICAL ADVANCES The best news for those suffering from venous disease is that treatment has improved with
the evolution of phlebology in the past two decades. Phlebology is the diagnosis and treatment of vein disorders, which include spider veins, varicose veins, chronic venous insufficiency, venous leg ulcers, congenital venous abnormalities and venous thromboembolism. Phlebology earned recognition in 2007 by the American Medical Association and the American Osteopathic Association as a self-designated medical specialty. This recognition of phlebology as a legitimate field of medicine was long awaited, says Dr. McHutchison, who specializes in this emerging medical field. “Now physicians, medical schools and insurance carriers are viewing vein care as medically necessary, as opposed to merely cosmetic,” she says, “and we can do more to bring relief to all those who suffer from venous diseases.”
JULY 2010
9
Before
After
p These are posterior before-and-after views of the same patient on page 9.
Medical insurance carriers are increasingly recognizing the need for phlebologic treatments and most insurance policies offer benefits for vein procedures. Topics related to venous disease are appearing in record numbers in medical journals and textbooks. Greater awareness among physicians is enabling them to make knowledgeable phlebology referrals and to educate patients on the ranges of treatments available.
vascular surgeons. The surgery to remove large varicose veins is painful, requires hospitalization and a general or regional anesthetic, and results in permanent scarring and a lengthy recovery time.
venous disease. Procedures require only micro-incisions and local anesthetic. Patients usually return to normal light activity immediately afterward and results are aesthetically pleasing.
A major leap came in 2002 with FDA approval of laser technology to treat varicose veins in an outpatient setting. It opened the door to treating less severe cases.
Major advances in phlebology have also occurred in the treatment of venous diseases. This often involves effectively controlling the backward blood flow of venous reflux, which requires sealing shut or removing the source of the visible varicosities. Because most of the blood in the legs is returned by the deep veins, the affected superficial veins, which transport only about 10 percent of the blood, can usually be removed or ablated without harm.
“Phlebology has evolved with advanced technology and knowledge of venous disease,” says Dr. McHutchison “Now we use ultrasound to evaluate veins. Treatments are short office procedures performed in the clinic setting and many patients return to work directly after their treatment with little or no down time.”
Diagnosis of venous disease begins with patient history and physical examination. Duplex ultrasound is often used to determine the cause and severity of the problem. Other diagnostic tools include CT scan, MRI and plethysmography, and laboratory evaluation related to venous thromboembolism.
In the past, only those with the most severe varicose veins underwent vein stripping by
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NEW TREATMENTS BRING BETTER RESULTS Today, vein stripping is all but obsolete. Phlebologists now have a number of lessinvasive outpatient procedures to treat
Modern techniques for sealing veins include sclerotherapy, cutaneous vascular laser, endovenous laser and radiofrequency occlusion. Sclerotherapy is the “gold standard” for treating leg spider veins. It involves injecting a sclerosing solution into the vein to seal them. The veins then shrink and gradually disappear. For deeper varicosities, ultrasound is used to “guide” the injections into the diseased veins
Before
After
p A 55-year-old man before and after bilateral endovenous laser ablation, ambulatory phlebectomy and sclerotherapy.
below the surface of the skin. This allows the medication to be administered to precise locations safely and accurately. The solution used for injections is FDA approved and safe, says Dr. McHutchison, and the procedure is relatively painless, so no anesthesia or sedation is needed. The Carolina Vein Center website (www. carolineveincenter.com) offers videos that show the remarkably quick improvement that results with sclerotherapy. Endovenous laser ablation and ambulatory phlebectomy are surgical techniques that replace vein stripping and are often performed in combination for the best results. They require only 2-3 millimeter incisions and local anesthetic or mild sedation. The micro-incisions are closed with sterile tape, not sutures, and leave barely a mark when healed. Ambulatory plebectomy is used to remove large bulging varicose veins at the skin’s
surface. Endovenous laser ablation uses a thin laser fiber (or catheter) inserted into the saphenous veins. The catheter delivers laser energy (heat) to the wall of large varicose veins, causing them to heat, collapse and seal shut. Contrary to the old-fashioned regimen of bed rest after vein treatment, patients today are instructed to walk as much as possible after treatment. This helps re-route blood to the deeper, healthier veins. A compression bandage is worn for three to four days after ambulatory phlebectomy and compression stockings are worn for short periods after all treatments to assist in healing and reduce any mild discomfort or swelling that may occur. “I could see an improvement as soon as I was able to take off the bandages,” says Mr. Strode. His treatments were followed up about a month later with sclerotherapy. According to Dr. McHutchison, patients return for two post-procedure visits to assess
the efficacy of treatment and evaluate the patient’s healing response to the therapy. Often additional sclerotherapy, with or without ultrasound guidance, is performed to ensure the best long-term results. CAROLINA VEIN CENTER IS BORN So impressed was Dr. McHutchison with the treatment of her own veins and at the encouragement of her friend and colleague Dr Cynthia Shortell, she decided to specialize in phlebology. At the time, she was an obstetrician/gynecologist and her 12year practice at Kaiser Permanente in San Diego, Calif., involved managing varicose veins in her pregnant patients. Dr. McHutchison began her phlebology training at Duke University as an observational fellow with Dr. Shortell, who is chief of vascular surgery. Subsequently, she completed an extended clinical preceptorship with John Mauriello, M.D., fellow of the American College of Phlebology and nationally known educator in the field. JULY 2010
11
She also trained with John Kinglsey, M.D., in Birmingham, Ala., another nationally known phlebologist. She is now a member of the American College of Phlebology, in addition to being board certified in obstetrics and gynecology. It’s a transformation that suits Dr. McHutchison well. “I love every minute of it. I can actually fix a patients problem and fixing people is not something you can always claim in medicine. I can take away someone’s pain and discomfort and make them so much happier.”
says Dr. McHutchison. “We spend a lot of time educating our patients and are on a first-name basis with all of them.”
Dr. McHutchison’s father, now-retired orthopedic surgeon Dr. Don Burt, embraced the saying while a student at Tulane University School of Medicine in the 1950s and later shared it with his daughter.
“Being a patient at Carolina Vein Center, you not only get a wonderful team to treat you,” says patient Sally Longacre, ”you get a whole new set of best friends!”
“Our practice philosophy is built around this motto,” she says. “Most patients come in with true discomfort. We treat veins and significantly improve their discomfort, which is liberating for them.” “Building relationships with our patients is another important aspect of our practice.”
PHOTO BY JIM SHAW
Today, Carolina Vein Center is a full-service vein clinic that treats both medical and cosmetic
vein problems. A plaque on the wall reads: “Of all the pleasures life can gain, ’tis not in treasures but relief from pain.” – Anonymous.
p Dr. Lindy McCutchison stands with her bilingual team at Carolina Vein Center.
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The Triangle Physician
Insurance
It’s
Hurricane Season!
Is Your Office Ready for Disaster? By Mike Riddick
I
t’s that time of year again, one which all of us who live in North Carolina have come to both love and dread. We love it because warm and sunny weather is great for golf, being at the beach or any other outside activity. We dread it, because it’s Hurricane Season. This year the National Weather Service has predicted an 85 percent chance of an “above normal” hurricane season, having between 14 to 23 named storms, eight to 14 of which will be hurricanes. Of those hurricanes, it predicts that between three and seven will be major hurricanes. The National Weather Service does a great scientific job with its hurricane predictions, but it doesn’t make any prediction on how many will hit the mainland United States. So what happens if a major hurricane hits North Carolina? We’ve all heard a hundred times how to prepare for a hurricane at home, but what should you do to protect your office from a disastrous hurricane? There are several key pieces to your insurance policy that I think you should consider to make sure you are ready for hurricane season. These pieces may seem small and unimportant until crisis strikes, and then you’ll wish you had them…in their correct format.
coverage. Some loss of income features are at what’s called “actual loss sustained” for up to 12 months. This means that if there is a loss, the insurance company will reimburse you for your actual revenue losses during that time period. This allows you to continue paying loans and employees, and drawing an income for yourself. I’d hate to lose my long-term employees because I couldn’t pay them during the nine months it took to rebuild my office. Other policies may offer a fixed coverage amount that is determined when the policy is written. Be aware of how long you have to be out of business before the policy kicks in. Data recovery and storage Second, think about your electronic data processing coverage and electronic records storage. If you’ve been in business for 15 to 20 years, I’m sure there are a lot of client files you don’t want to lose.
Mike Riddick is president of Riddick Insurance Group Inc., an independent insurance agency in Raleigh. For 10 years, he has been helping professionals protect their assets through insurance and financial planning. Riddick Insurance Group specializes in property, casualty, liability and life insurance planning for small business owners. Mr. Riddick can be reached at (919) 870-1910 or mike@ riddickinsurancegroup.com.
If your office was destroyed by a storm (or any other peril), would the insurance company help you restore all of your records? Are you regularly backing up your records? Has the company you’ve hired to handle that run a test to make sure the backup is working properly? Replacement of perishables Finally, but very important, do you have coverage to replace medicines and other perishables that must be kept at certain temperatures? Certain doctors keep very expensive drugs in their offices that must be refrigerated. Ask your insurance agent: • How long can the power be out before you file a claim? • Does your coverage include power loss from off-site causes? I sincerely hope we don’t have any large storms this year, especially hurricanes hitting the United States coast. Still, it’s best to be prepared. Have a contingency plan for office operations and an emergency preparation plan to get the office ready for the storm. And make sure your insurance policy is ready, so when all else fails, it can pick you up and make you whole again.
Income-loss coverage First, be aware of your loss of income JULY 2010
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Sports Medicine Dr. Mark Galland is a board-certified orthopaedic surgeon, specializing in sports medicine, and practicing in Wake Forest and North Raleigh. He serves as team physician and orthopaedic consultant to the Carolina Mudcats, the AA affiliate of the Major League Cincinnati Reds, as well as several area high schools and colleges. He can be reached at (919) 562-9410 or by visiting www.orthonc.com or www.drmarkgalland.com.
Tommy John Surgery
has Major League Success
By Mark Galland, M.D.
With ever-increasing success rates, many pitchers can expect to return to play with the same skill they had prior to the injury. So in today’s game, many view the once career-ending injury as just another line in the media guide.
E
very season baseball fans lament the loss of some of their favorite pitchers to elbow injury. It is so common an occurrence that it is no longer a surprise; many fans seem to expect that one or more of their favorites will eventually fall prey to “Tommy John.”
League game this season has had Tommy John surgery. The UCL injury is a concern not only for Major Leaguers, but for players at the high school level, as well. In fact, more high school baseball players sustain this injury and require surgery than all professional and collegiate baseball players combined!
Doctors call the surgical treatment for the injury a UCLR (ulnar collateral ligament reconstruction). Baseball players and fans
Consider that for a moment. These injuries are occurring right now, on your hometown diamonds and to young athletes who
you know. The reasons are myriad. Poor mechanics, elevated pitch counts, too many innings pitched, inadequate off-season rest and training – the list is practically endless. The classic story is one in which a pitcher is throwing a slider and feels a sudden onset of pain and a “pop.” Sometimes the onset of pain is sudden, but in most cases it is a gradual process of persistent pain on the medial side of the elbow. Athletes who
Ant. bundle
have named it after the Los Angeles Dodgers pitcher who underwent the first UCLR in 1974. It was one of the most significant advances in sports medicine. Approximately one of every nine pitchers who will make an appearance in a Major
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The Triangle Physician
Post bundle
Transverse lig.
develop this condition have pain in the elbow during and after throwing activities. They may also develop numbness and tingling in the hand, as a result of stretching the nearby ulnar nerve at the elbow. Anatomy of an elbow A consideration of the anatomy of the ligament may help to understand. The ulnar collateral ligament is on the medial (next to the body) side of the elbow. It is a thick band of ligamentous tissue that forms a triangular shape along the medial elbow. It has an anterior bundle, posterior bundle and a thinner, transverse ligament.
The procedure is not unlike that done for reconstructive knee surgery of the anterior cruciate ligament (ACL), which has revived the careers of many professional football players. In fact, sometimes UCLR is referred to as the “ACL of the elbow.” Before the breakthrough UCLR, baseball saw top pitchers, such as Sandy Koufax, retire with elbow problems, referred to simply as “dead arm.” A torn ligament was the end of the line, or for a lucky few, a ticket to the broadcast booth or the coaching staff.
Recovery Though the surgical procedure has undergone only minor refinements, the major advancements have come in the post-operative rehabilitation, increasing the success rate from about 60 percent a decade or so ago. The surgery requires a full year of rehabilitation and typically another year of pitching before returning to pre-injury form. During the recovery process, the body must convert a tendon into a ligament. (A ligament connects bones, stabilizing a joint. A tendon attaches muscle to the bone.) It is very weak immediately after the surgery, and the rebuilding process must be gradual. Many note an increase in velocity after the process is complete. The reasons are yet unclear. Hard work and physical maturation of the athlete are primary considerations. Some coaches believe emotional maturity is a factor. I have had more than one pitching coach tell me, “I’ve seen guys come back better workers because now they’ve got a wake-up call.”
Tommy John Reconstruction, Figure of 8 Technique
Benefits of surgery As the success rate of the surgery increases, so does the number of cases. Ten years ago, doctors were more likely to recommend rest for a partial ligament tear. The numbers now favor surgery.
The UCL is the main source of stability for the elbow during throwing. It can be damaged by overuse and by repetitive stress, such as the throwing motion. If it does not heal correctly, the elbow can be too loose or unstable.
Non-surgical success rate of healing partial tears is lower than initially believed. With “conservative” treatment, players can be hampered by the injury for two or three years, as they rest the injury, then try to return – “rinse, lather, repeat.”
Tommy John surgery Surgical treatment is designed to restore stability of the elbow during throwing. It is successful in returning the pitcher to the mound 85 percent of the time.
We have learned from these “failures,” and now recommend and perform reconstruction soon after diagnosis. This aggressive approach is counter to most surgeons’ way of thinking. Contrary to popular belief, most surgeons are conservative and reluctant to “rush” to operative treatment.
Amazingly, the surgical procedure hasn’t changed much since it was pioneered by Frank W. Jobe, M.D., for Tommy John. A tendon is removed from the patient’s wrist and grafted into the elbow – woven in a figure-eight pattern through tunnels drilled in the humerus and ulna bones – recreating the normal anatomy of the ligament.
Palmaris longus tendon used to reconstruct UCL
With ever-increasing success rates, many pitchers can expect to return to play with the same skill they had prior to the injury. So in today’s game, many view the once career-ending injury as just another line in the media guide. JULY 2010
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Neurosurgery
Effectiveness inCervical Spine SurgeryVaries
of New Appoaches
By Dennis E. Bullard, M.D., F.A.C.S.
Virtually all large studies show that correction and restoration of the normal curvature of the neck, relief of the narrowing around the nerve roots and stabilization of this portion of the spinal column results in improved range of motion rather than decreased range of motion.
O
ver the past decade, multiple new technologies have developed for the treatment of cervical spine problems. These include different types of surgical approaches, the use of different instruments used in surgery and the development of newer biological materials. Several of these have proven extremely effective and have clearly improved the outcomes from surgery. Others, however, have not shown to be as effective despite extensive interest. This editorial outlines briefly several of these topics and discusses the current level of understanding of their effectiveness. Anterior cervical diskectomy and fusion with plating (ACDFP) Since the development of the anterior cervical approach to the spine, the high level of success achieved with one- and twolevel fusions has become very consistent throughout the world. Most reported series show that one- to two-level fusions have a 90 percent to 98 percent success rate.
Triangle Neurosurgery currently sees a 98 percent success rate with one-, two- and three-level anterior approaches by using stem cell technology, dynamic plating and interbody cages. Rather than using the patient’s own bone, which is often very painful, or cadaver bone, which has a lower success rate and a very limited potential of transmission of diseases, the practice uses cages. Cages are extremely strong, long-lasting and provide a large internal opening through which bone can grow. When combined with stem cell technology using FDA-approved adult stem cells, the success rate is extremely high and fusions are seen at an earlier date. It is important that patients understand the term fusion does not imply that range of motion of the neck will be severely limited after surgery. Virtually all large studies show that correction and restoration of the normal curvature of the neck, relief of the narrowing around the nerve roots and stabilization of
this portion of the spinal column results in improved range of motion rather than decreased range of motion. There are also multiple types of anterior plates that can be used. Triangle Neurosurgery believes that plates allowing movement provide a stronger construct and are more likely to provide longterm success than the older, more static plates that allow movement only where the screws are inserted. The high rate of success achieved with most constructs may make these fine details seem unnecessary, but the difference between a 95 percent and a 99 percent success rate is extremely important to the 4 out of every 100 patients who would potentially have had an unsuccessful result.
Dr. Dennis Bullard is a board-certified neurological surgeon and a fellow of the American College of Surgeons. He graduated from St. Louis University Medical School in 1975. He completed his internship and residency at Duke University, and a fellowship in neurology at the National Hospital for Neurologic Disease in London. He was on the faculty at Duke University as an associate professor in neurosurgery from 1982 through 1987. Dr. Bullard has been in practice in Raleigh since 1987. He is a former chairman of the Joint Section on Tumors and the Stereotactic and Functional Section of the Congress of Neurological Surgeons and the American Association of Neurological Surgeons. He has served as chairman of surgery and neurosurgery at Rex Hospital. His major interests are spinal problems with a special emphasis on the cervical spine and minimally invasive procedures for the lumbar spine. For more information, call (919) 235-0222 or visit www.triangleneurosurgery.org.
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The Triangle Physician
Triangle Neurosurgery, PA
A Complete Spine Care Center Dr. Dennis E. Bullard MD, FACS is a Board Certified Neurological Surgeon and a Fellow in the American College of Surgeons. He was trained at Duke and was on their staff as a tenured Associate Professor of Neurosurgery. He is a neurosurgeon who has been practicing for 28 years and is always striving for the most current and effective care for his patients. He is the recipient of the 2010 first place award given by the American Association of Neurological Surgeons for his research in cervical spine surgery. He has been honored with the Patients’ Choice Award and has been elected continuously to the lists of America’s Top Rate Physicians and Best Doctors in America. He is a member of the North Carolina Spine Society and elected to the International Who’s Who in Medicine. His major interests are spinal problems with a special emphasis on the cervical spine and minimally invasive procedures for the lumbar spine. Triangle Neurosurgery provides a unique blend of personalized attention to each patient with the latest advancements in state of the art technology. This results in compassionate and comprehensive care delivered through conservative management or surgery. Our emphasis is patient centered and we recognize the importance of helping patients return to an active and healthy lifestyle. Triangle Neurosurgery, PA 1540 Sunday Drive, Suite 214, Raleigh, NC 27612 Phone: 919-235-0222 Fax: 919-235-0227 triangleneurosurgery.org
Posterior approaches to the cervical spine In the past, a posterior approach to the cervical spine was often the first choice among surgeons. It had a high success rate for certain types of problems, but as the anterior approach developed it has been used less frequently. There is still a role for minimally invasive posterior procedures, such as multilevel laminectomy and laminoplasty, and this technology is still used when appropriate. Although these may not be the best choice for most patients, Triangle Neurosurgery is experienced with taking these approaches.
dysfunction is often more than just at the level of the disc.
improvement over the current technology before using them routinely.
Stand-alone devices More than five companies currently have devices on the market that include a cage and an anterior portion, which allows insertion of screws into the vertebral bodies. These have become very popular, largely because of their ease of insertion and the fact that they require less time to be placed.
In conclusion, ACDFP is still the gold standard for cervical surgery. It has consistently shown to be very effective in the hands of multiple surgeons and over a long time period.
Triangle Neurosurgery is actively involved in the development and use of these, but is waiting to show that these are an
Triangle Neurosurgery stays abreast of new and improving technology and patients are briefed on the rationale behind choices. It is important that the patient understands the problem and is an active participant in the selection of treatment.
Combined anterior/posterior procedures In the past, the use of an anterior approach alone was somewhat controversial when it involved greater than two disc spaces. Triangle Neurosurgery has published several papers and kept an ongoing record of the success rate with this. We find that when appropriate, the anterior procedure alone often is far superior to a combined anterior/posterior approach. In traumatic situations or where the bone quality is poor, an anterior approach combined with a posterior approach might become necessary. Artificial disc It has been a very popular conceptual approach to attempt to achieve normal movement in the neck by the use of inserted instruments called artificial discs. These are usually combinations of metal and/or polyethylene. The idea of restoration of normal movement and continued full range of motion at the level of approach is very appealing. However, the empirical results seem too problematic for this technology to be used in the majority of patients. When and if any of these artificial discs become effective enough to compare well to anterior cervical diskectomy and fusion, then they will be used more frequently. At the current time, what is achieved is more of an uncontrolled movement in the neck, and
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Womens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
Community Care
Charity Susan G. Komen AYou Can for the Cure: Trust “All year long we put that money, along with funds from annual giving and other events, into the mission, funding screening, education, treatment and post-treatment programs in our 19-county service area.” – Pam Blondin, Komen NC Triangle Executive Director
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pproximately 25,000 supporters gathered June 14 in Raleigh for the 14th annual Komen NC Triangle Race for the Cure, now the largest footrace in the Carolinas, raising nearly $2 million to serve women in this community. Among the sea of pink were hundreds of survivors, volunteers and activists.
education for uninsured or underinsured women right here in our backyard,” said Komen NC Triangle Director of Community Programs Dr. Nadine Barrett. The remaining 25 percent goes to fund ground-breaking breast cancer research at leading institutions, including the University of North Carolina, Duke National Institute of
“To raise $2 million at one event is amazing and humbling, but for Komen, the Race for the Cure is just the beginning,” said Komen NC Triangle Executive Director Pam Blondin. “All year long we put that money, along with funds from annual giving and other events, into the mission, funding screening, education, treatment and post-treatment programs in our 19-county service area.” Komen NC Triangle is an affiliate of Susan G. Komen for the Cure. Komen for short, it is the only nonprofit organization working to end breast cancer at every stage, from the causes, to the cures, to the pain and anxiety of every moment in-between, according to Blondin. “Through the extraordinary efforts of our community grant partners, 75 percent of the funds raised will provide services and
Environmental Health Sciences and Wake Forest University Baptist Medical Center.
Recent recognitions further demonstrate the high regard for the charity. • Charity Navigator, an independent evaluator of charity financial health, has awarded Komen the maximum four-star rating for three years in a row, citing fiscal soundness and sustainability of programs. Charity Navigator President and Chief Executive Officer Ken Berger said that this rating “differentiates Susan G. Komen for the Cure from its peers and demonstrates to the public it is worthy of their trust.” • The 2010 rankings of nonprofit organizations from global market research firm Harris Interactive ranked Komen for the Cure the No. 1 most valuable nonprofit brand and the charity people are most likely to donate to. Harris Interactive Senior Vice President of public affairs Justin Greeves said of the topperforming nonprofits: “They are working to solve many of society’s most complex and relevant problems in efficient, new and innovative ways, and have achieved personal relevance in many of our lives − that is why they are at the top.” • The Komen NC Triangle Affiliate was named the 2008-2009 international Affiliate of the Year for its stewardship of funds, impact on the Triangle community and leadership in the fight against breast cancer. For more information, visit www.komennctriangle.org.
Best in its class Komen for the Cure is widely recognized as the best in its class of nonprofit organizations. Komen NC Triangle’s Director of Development Laura Tormey cited public trust established by responsible fund-raising and cost-effective spending practices. JULY 2010
19
Business Management
Marketing is Present in a Successful Practice By John Reidelbach
As the health care market becomes increasingly competitive and profitability more difficult to manage, the need for medical practices to build and maintain a strong marketing competence has grown.
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arketing is about presence. Marketing, when done professionally and thoughtfully is very powerful. Marketing may be as simple as your logo on a T-shirt. Anyone who doesn’t believe in marketing has only to think about the millions of Americans who eat yogurt and actually believe they like it! Marketing is a well-thought out blueprint or roadmap that provides the foundation and direction for your practice. It is a vital component of your strategic business plan. The plan helps you achieve your business objectives. A marketing plan is not engraved
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The Triangle Physician
in stone, but should be fine-tuned as the business evolves. Marketing objectives should be clearly defined and consistent with overall corporate objectives. Goals should be specific and measurable and may be determined in areas such as awareness, revenue, number of patients or profit goals. You should also think about how you want your business to be perceived by your patients and visitors to the practice. Your positioning should be clear and succinct. Communication strategies should deliver: • Brand name recognition
• Brand name equated with excellence • Brand name you can trust • Branding that truly defines your patients • Branding that presents an image that lasts: service/value, warm/human, empathic and emotionally connected. Marketing does matter! Practices that do not market run the risk of being supplanted by the competition. Exceptional practices have stagnated in their market areas because the patients, the insurance companies, and employers have no idea about the group’s skill set, patient satisfaction scores and dedication to excellence!
John Reidelbach’s career in health care spans more than 20 years and all facets of administration within physician practices, hospitals and large health care insurers. He founded Physician Advocates Inc. in 1996. Today, he assists health care entities in all aspects of practice management, operation, strategic development and implementation, education, contract negotiations, data analysis and capital funding. His credentials include degrees in engineering and education, and a master’s in business administration. Mr. Reidelbach has designed several health care management entities, including independent physician associations, physician practice management companies, management service organizations and group practices. His experience includes developing equity ownership structures, financial incentives, network administration, and information systems selection and implementation. He also has developed detailed analysis tools for health care providers and product vendors. Mr. Reidelbach can be reached in North Carolina at (919) 321-1656 or in Atlanta at (404) 664-9060; and by e-mail to info@mdpracticeadvice.com.
Why market your practice – because you want to grow or maintain your volume of new patient visits. The days of a doctor hanging a shingle outside the door are over. Just because you build it, does not mean they will come. Although physicians do not want to “advertise” per se, you can promote yourself in a helpful, non-threatening way. You need to find creative ways to increase your patient volume, whether it is referrals from current patients, specialists in town or third-party payers. Even with the best clinical skills and most compassionate care, a medical practice needs to understand and implement basic marketing strategies if it is to be successful and remain competitive. Some medical practices are fortunate enough to be well marketed, with an administrator and physician leadership that understands the importance of a marketing and development plan. Most practices however, are not.
Part and parcel of any strategic business plan is a marketing and practice development plan. When revenues are down, you need to increase marketing, not decrease it as you might be inclined. This is a hard sell in most medical practices. Every practice should know how many new patients per month it takes to remain profitable and take action to insure that flow. Marketing can be as subtle or bold as you dare, as long as it produces adequate results. There is no doubt that to get to the top of any field requires hard work. But, sometimes
hard work is not enough. Developing your business requires resources. Not just capital, but experts. Experts who can position your company to get noticed and to make sure that your potential patients, employers in the area and the managed care companies understand what you offer. When we negotiate managed care contracts, we bring the payers in to sit down to the table so that we may educate them about the practice, about those intangibles that set you apart from the competition. We make sure the physical plant is well organized and sparkling, we serve a light breakfast or lunch or snack, depending on the time of day we meet. We market you to the payers. Call it a dog and pony show if you must, but it gets results. In summary, the strategic marketing plan is the foundation for the marketing direction of your company. Use your marketing plan as the framework for providing the direction of your business, to achieve your objectives, and to successfully build and grow your practice.
Some practices will tell you that their intuitive knowledge and understanding of their market has led to their success without the need for a formal marketing strategy, while still others use chance and hope in a highly competitive marketplace which is highly inadvisable. These three approaches characterize the widely varying status of marketing management and strategy in medical practices across the country. As the health care market becomes increasingly competitive and difficult to manage profitably, the need for medical practices to build and maintain a strong marketing competence continues to grow.
JULY 2010
21
Sports Medicine
Athletes Get Back in the Game With
ACL Surgery By Douglas L. Gollehon, M.D.
©www.istockphoto.com/vm
“I twisted my knee, felt a pop and the knee gave way.” It’s a statement so often heard from the competitive or recreational athlete that almost always results in an eventual confirmed diagnosis of anterior cruciate ligament tear. In short, “I tore my ACL.”
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njury to the ACL usually results in a complete tear, with no potential for spontaneous healing. Today, minimally invasive surgical repair improves the chances of healing, so athletes of all ages can remain active and even participate in sports. Biomechanics of ACL Stability of the knee is dependent on two major ligament systems, which connect the femur to the tibia. The collateral ligaments
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are located on the external aspect of the knee and limit sideways motion. The second system comprised of the anterior and posterior cruciates is located within the joint. The anterior cruciate ligament is the primary ligamentous restraint limiting forward motion of the tibia and rotation of the knee during pivoting maneuvers. The posterior cruciate limits backward motion of the tibia.
The injured athlete usually describes an ACL tear as occurring when planting and cutting on the involved leg. He or she frequently hears or feels a pop and thinks the knee has come apart or shifted out of normal position. Commonly, other athletes on the playing field also hear a pop, as the ACL injury occurs. The athlete usually cannot continue to play and the knee swells noticeably within a few minutes to hours after injury due to bleeding in the joint.
prevalent in females. This female predisposition to ACL tears may be due in part to knee anatomy and small ligament size when compared with males. There is also continued research evaluating specific athletic technique as a predisposing factor.
A fellow of the American Academy of Orthopaedic Surgeons, Dr. Douglas Gollehon has been affiliated with Cary Orthopaedic & Sports Medicine Specialists P.A. for the past 25 years. He earned his medical degree from Eastern Virginia Medical School in Norfolk, Va. He completed his residency at Louisiana State University and a sports medicine fellowship from the Hospital for Special Surgery in New York City. Dr. Gollehon can be reached at (919) 467-4992 or www.caryortho.com.
Significance of the initial injury may not be recognized until the athlete returns to his sport and has a recurrent episode of giving way. If the problem is untreated and the athlete continues with sports, the knee becomes more unstable, as the remaining secondary ligament and cartilage structures are abnormally stressed. This results in predictable, repeat injuries with resultant joint surface damage, cartilage tears, other ligament injuries and the development of early arthritis. Prevention and predisposition Preventative measures can be taken to avoid the potentially season-ending ACL injury.
Diagnosis Properly managing ACL requires the injury be examined by an orthopaedic surgeon. Advances in sports medicine have led to a steadily improving ability to recognize this type of injury through more advanced clinical examination maneuvers.
Athletes involved in cutting and twisting sports, such as soccer and basketball, are at greater risk for ACL. It is also more
The object of this surgical reconstruction is to ensure a stable knee, which allows normal sports participation while avoiding repetitive knee injuries. To further ensure an excellent result, attention to precise surgical technique and a detailed postoperative rehabilitation regimen are a must.
(thighbone)
Articular cartilage lines the bones, cushoning your joint.
The medial collateral ligament (MCL) runs down the inside of your knee joint. It connects the femur to the tibia and limits sideways motion of your knee.
The anterior cruciate ligament (ACL) connects the femur to the tibia in the center of your knee. It limits rotation and the forward motion of the tibia
ACL injuries seem to have little relationship to the athlete’s level of muscle strength and flexibility. Instead, they are more closely related to jumping and twisting sports, family genetics, knee anatomy and gender.
Surgery and beyond In the past, treatment for ACL involved bracing the knee for light activity and giving up vigorous sports. As surgical techniques have improved during the past 10 years, reconstruction of the torn ACL using minimally invasive arthroscopic approach has proven to be the treatment of choice.
Femur
The lateral collateral ligament (LCL) runs on the outside of your knee. It limits sideways motion.
Soccer athletes should always wear proper shoes The meniscus is with short cleats to prevent cartilage that absorbs shock in your joint. excessive forces at the knee when pivoting. Avoiding sudden, dramatic cuts in a sideways direction with all the weight on a planted, cleated foot can minimize risk. Experience in the sport also decreases the likelihood of injury, but there are no guarantees.
seek medical care, swelling and pain in the knee gradually subsides over a few days to weeks.
The ACL arthroscopic surgery is performed on an outpatient basis. Pain afterward is usually not severe and can be controlled through use of ice and pain medication. Rehabilitation is started within the first few days after surgery; and by six weeks, a jogging program can be implemented. The athlete can expect to return to sports four to six months post-op.
The posterior crudate ligament (PCL) also connects the femur and tibia. It limits backward motion of the tibia.
An MRI scan might be considered if the diagnosis is not clinically obvious due to early swelling and pain, but surgery is generally never needed for diagnosis. Ordinary X-rays are helpful only in the infrequent times when a small piece of bone is pulled loose at the ligament attachment site.
Surgery is usually not recommended until at least four weeks following injury. These first weeks are needed to allow reduction in pain and swelling, while regaining normal muscle tone and range of motion. If surgery is delayed for an extended period of time until convenient for the patient’s school or work schedule, the athlete should take additional precautions to avoid activities which may cause re-injury.
Normal variations in knee laxity from person to person cause some to have a much looser knee after ACL injury than others. However, almost no one feels they have a normal knee after a complete tear. If the athlete does not
The surgical success we now experience allows the surgeon to recommend this very important option for both the younger and “more experienced” athletes who wish to maintain an active lifestyle.
Tibia
(shinbone)
JULY 2010
23
News Welcome to the Area
CME Courses at Duke
Laura Katherine Bliss , MD
Bryan Kenneth Tepper , DO
Family Practice Bliss Medical Group, Mebane
Emergency Medicine 800 Laurel Springs, Durham
Carlos Javier Guevara , MD
Jill Rene Tichy , MD
Radiology Duke University Hospitals, Durham
Internal Medicine University of North Carolina Hospitals, Chapel Hill
Larry Koreen , MD Duke Eye Center, Durham
John David Wylie , MD
Margaret Michele Martin , MD
Radiology Duke University Hospitals, Durham
Pediatrics 122 W Woodridge Dr, Durham
Devon Eva Begley , MD
Elizabeth Alexandra Reddy , MD Internal Medicine DUMC Div of Infectious Disease, Durham
Rachel Elizabeth Vinson , MD Pediatrics Duke University Hospitals, Durham
Eugene Pedro Ceppa , MD General Surgery Duke University Medical Center, Durham
Kevin Robert Kuzma , MD Orthopedic, Hand Surgery Duke University Hospitals, Durham
Spencer Robison Koch , MD
Ultrasound Guided Regional Anesthesia Preceptorship Course Location: DUMC Credits Offered: AMA PRA Category 1 - 20.00 July 15–16, 2010 — 1:00 PM
Essentials of Transradial Angiography and Intervention
Internal Medicine University of North Carolina Hospitals, Chapel Hill
Kacey Young Eichelberger , MD Obstetrics and Gynecology University of North Carolina Hospitals, Chapel Hill
Naina Khera-McRackan , MD Obstetrics and Gynecology University of North Carolina Hospitals, Chapel Hill
Highlights from ASCO 2010: The Era of Personalized Cancer Treatment Location: Umstead Hotel Cary NC Credits Offered: AMA PRA Category 1 - 6.75 July 24, 2010
Marvaretta Miesha Stevenson , MD
Amber Marie Jarvis , MD
Internal Medicine Duke University Medical Center, Durham
Duke University Medical Center, Durham
Duke University Medical Center Division of Vascular & Interventional Radiology, Durham
Rodney Kevin Sessoms , MD
July 26–30, 2010
2010 Duke Radiology Summer Postgraduate Course Location: Kingston Plantation Credits Offered: AMA PRA Category 1 - 23.00
Ultrasound Guided Regional Anesthesia Preceptorship Course
Corey Adam Thompson , MD
Location: DUMC Credits Offered: AMA PRA Category 1 - 20.00
Orthopedic Surgery Wake Orthopaedics, Raleigh
August 16–18, 2010
Eric Furman Strother , MD
Preceptorship in Intraoperative Transesophageal Echocardiography
Raleigh Pathology Laboratory Associates, Raleigh
Rachel Marie Peragallo , MD Obstetrics and Gynecology Duke University Hospitals, Durham
Ashley Love Sumrall , MD Duke University, Durham
Kunwardeep Singh Sohal , MD Internal Medicine University of North Carolina Hospitals, Chapel Hill
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The Triangle Physician
13th Annual Duke Cardiothoracic Update & TEE Review Course
August 9–11, 2010
Rhett Churchill Mays , MD
Internal Medicine Duke University Hospitals, Durham
August 5–8, 2010
Capital Pediatrics & Adolescent Center, Raleigh
Christine Norton Sillings , MD
David Yung Ming , MD
August 2010
Laura Lynn Steinberg , MD
Orthopedic Surgery Duke University Medical Center, Durham
Internal Medicine Duke University Hospitals, Durham
Location: Hilton/Rosemont Chicago O’Hare Credits Offered: AAFP - Prescribed - 6.25; AMA PRA Category 1 - 7.25
Location: Hilton Head Island, SC Credits Offered: AMA PRA Category 1 - 28.25
Anesthesiology Raleigh Family Health Care, Raleigh
Upcoming Events September 11, 2010
The Gail Parkins Memorial Ovarian Awareness Walk & 5K Run Location: Sanderson High School - Raleigh, NC
8:00 am Registration Opens 8:30 am Run starts
Internal Medicine 500 Beaman Street, Clinton
Robert Kamiel Lark , MD
NC Cardiovascular Update 2010
Location: Embassy Suites Credits Offered: AAFP - Prescribed - 6.25; AMA PRA Category 1 - 7.25
Complex Cases in Primary Cases: Case-Based Interactive CME
Pediatrics Duke University Hospitals, Durham
September
5500 Dixon Drive, Raleigh, NC 27607
Matthew Daniel Pepper , MD Pediatrics Duke University Hospitals, Durham
July 15–18, 2010
Complex Cases in Primary Cases: Case-Based Interactive CME
July 31, 2010
Sarah Hart-Unger , MD
July
July 23, 2010
UNC Gastroenterology, Chapel Hill
John Adam Grezaffi Jr, MD
For more information www.med.unc.edu/cme
September 17–18, 2010
James Darrell Laudate , MD
Jeffrey Bryan King , MD
Internal Medicine Duke University Hospitals, Durham
UNC-Chapel Hill CME Courses
Location: Grove Park Inn Credits Offered: AMA PRA Category 1 - 13.50
Pulmonary Disease and Critical Care, Internal Medicine Duke University Medical Center, Durham
Mitchell Collins Black , MD
Location: New York City, NY Credits Offered: AMA PRA Category 1 - 6.50
Heart Failure 2010
Internal Medicine Duke University Hospitals, Durham
July 22–24, 2010
Alice Lee Gray , MD
Internal Medicine Duke University Hospitals, Durham
16th Annual Perspectives in Breast Cancer: Surveying and Debating Prominent Issues in Breast Cancer
Duke Clinical Medicine Series: Cardiology Conference
Russell Barnes Rauls , MD
Tilak Upendra Shah , MD
August 28, 2010
Christopher Stanley Roser-Jones , MD
Pediatrics University of North Carolina Hospitals, Chapel Hill
Obstetrics and Gynecology Duke University Hospitals, Durham
July 12–14, 2010
Save Date
Location: R. David Thomas Center Credits Offered: AMA PRA Category 1 - 8.25
Anitha Kamla Jain-Rodriguez , MD
Michael Patrick-Bousson Smrtka , MD
July 2010
Duke CME Courses
Radiology University of North Carolina Hospitals, Chapel Hill
Duke University Medical Center, Durham
Orthopedic Triangle Orthopaedic Associates, PA Durham
See Web Site for more information: http://cmetracker.net/DUKE/Courses.html
Location: Duke North OR Credits Offered: AMA PRA Category 1 - 27.00
5K Run
“It Whispers, So Listen” Educational Forum open to the public. 8:00 am Registration begins for forum and/or walk 9:30am Forum begins at Sanderson High School. Educational Forum presented by Duke and UNC GYN Oncologists. Once you are educated and know the symptoms, join us for the walk that helps raise money and awareness for ovarian cancer…
The Ovarian Awareness Walk 2-mile walk 9:00 am – Registration begins 10:30 am – Start walking for a cure! Please note: Walk is slightly hilly at the end. http://www.ovarianawareness.org/ September 26, 2010
2010 Start! Triangle Heart Walk Time: TBD Location: RBC Center, 1400 Edwards Mill Rd. Raleigh, NC 27607 http://starttriangle.org/
Updated Websites Wake Radiology released a newly updated website wakerad.com containing over 300 pages of information and education.
Cardiology
Cary Cardiology
Expands Services with Addition of Electrophysiologist
With the addition of Pavlo I. Netrebko, M.D., a boardcertified electrophysiologist, Cary Cardiology offers a full spectrum of cardiac care.
are at risk of forming blood clots inside of the heart and suffering subsequent stroke. “This disease is multifactorial and measures to correct predisposing conditions are not always successful,” says Dr. Netrebko. “Early diagnosis and expert treatment greatly increase chances of restoring quality of life.”
Dr. Netrebko’s main area of expertise is in the management of cardiac arrhythmias and implantable devises. He earned his fellowship in p Pavlo I. Netrebko, M.D. ablation of atrial fibrillation at Geisinger Health Care System in Danville, Pa. “In some minimally symptomatic older Atrial fibrillation is the most common patients, protection from a stroke with a arrhythmia, affecting millions of Americans. blood thinner and control of the heart rate Typically the disease prevalence increases with a simple medication is often sufficient,” with age, however some are stricken as early says Dr. Netrebko. “In a symptomatic patient, a more complex antiarrhythmic medication as their 30s. often in conjunction with electrical Affected patients suffer from rapid, irregular cardioversion is used to keep heart in regular heartbeat, as well as symptoms of low rhythm.” cardiac output due to loss of cardiac synchrony, such as tiredness, lack of energy If antiarrhythmic medication alone fails to and poor quality of life. Some of the patients control atrial fibrillation, a minimally invasive
procedure may help. Radiofrequency catheter ablation targets areas of the heart that harbor arrhythmia triggers. The procedure is especially successful in those who have had atrial fibrillation for a shorter time. “A heart that stays in atrial fibrillation for years often undergoes changes that make restorations of the normal rhythm impossible,” says Dr. Netrebko. Dr. Netrebko also is board certified in cardiovascular disease and internal medicine. He earned his medical degree in Dnepropetrovsk, Ukraine. He completed his internal medicine residency at Hahnemaan University in Philadelphia, and a cardiology and cardiac electrophysiology fellowship at Geisinger. For more information, contact Cary Cardiology at (919) 233-0059 or visit www.carcardiology.com.
JULY 2010
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Sports Medicine
New Developments Advance
Rotator Cuff Surgery
By Claude Moorman III, M.D.
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n the past two to three years, there has been a paradigm shift in the surgical treatment of rotator cuff tears. This centers around advances in 1) minimally invasive surgery; 2) understanding of biceps pathology; and 3) extracellular matrix grafts and partial repair strategies in the management of massive rotator cuff tears. Whereas five-to-10 years ago most rotator cuff repair surgeries were done through 6-to-10 centimeter incisions with either detachment or splitting of the deltoid muscle, now the surgery is performed in most centers through 4 millimeter “pinhole� portals. This results in a major decrease in post-operative pain and has allowed the majority of these surgeries to be done in an outpatient setting. This less-invasive approach also has been paired with regional anesthesia (nerve
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The Triangle Physician
block), so most patients will not require intubation or general anesthesia. With the blocks lasting some 12-to-14 hours post-
an earlier and more effective recovery from this procedure.
Minimally invasive techniques, coupled with an improved understanding of the biceps, and promising techniques for the management of massive tears have revolutionized care and improved our expectations for successful outcomes. surgery, the requirement for narcotic pain medicine is much diminished. There also has been a considerable amount of recent research helping to improve techniques for suture anchor (like dry-wall screws) placement and configuration to make the repair strong enough to perform early rehabilitation. These advances have served to minimize the pain of surgery, and facilitate
New view on pain source The biceps tendon recently has been identified as a major source of pain in patients who have rotator cuff injury. Recent research done by our team at Duke Sports Medicine Center shows that this is effectively treated by either release (tenotomy) or by repair (tenodesis).
Another innovation has been to use an extracellular matrix (ECM) to patch the irreparable defect and cover the ball. This technique has been pioneered by one of my partners, Dr. Alison Toth. Various materials have been used successfully for this purpose and the favored material currently is a pigskin-derived patch. This has been treated to remove any of the surface material (antigen) that the body would recognize and reject as foreign material. There is an active prospective randomized trial ongoing at Duke to further evaluate this promising technology. successful in a large number or our patients In summary, the recent advances in rotator even when the tear cannot be brought cuff tear treatment have made it a safer, more comfortable and more successful surgery. entirely back over the top of the ball. Minimally invasive techniques, coupled with The key is to get as much of the humerus an improved understanding of the biceps, and covered as possible by a technique of margin promising techniques for the management of convergence, in which the two bands of the massive tears have revolutionized care and “suspension bridge” are brought together to improved our expectations for successful allow restoration of the “force couple,” or outcomes. Patients can expect less pain, ability of the cuff to bring the ball back into quicker progression to strengthening and motion work, and a fuller recovery than ever the socket. NEWSOURCE-JUN10:Heidi 6/22/10 9:41 before. AM Page 1
Dr. Claude Moorman is professor of surgery (orthopaedics), director of the Duke Sports Medicine Center and head team physician for Duke University. He earned his medical degree in 1987 from the University of Cincinnati College of Medicine. After completing an orthopaedic residency at Duke University Medical Center in 1993 and a sports medicine fellowship at Cornell’s Hospital for Special Surgery in New York in 1994, Dr. Moorman returned to Duke University Medical Center as a clinical assistant professor in orthopaedics until 1996. From 1996 to 2001, he served as the director of sports medicine at the University of Maryland Medical Center and head team physician for the National Football League SuperBowl champion Baltimore Ravens. Dr. Moorman’s clinical interests include shoulder instability and rotator cuff problems, knee cartilage and ligament injury, and he specializes in minimally invasive arthroscopic surgery. Research interests include multiple ligament knee injury, shoulder instability and muscle strain injury. For more information, call (919) 668-3087. For more information on Duke Sports Medicine Center visit www.dukesportsmedicine.org.
The results suggest that for high-level athletes there may be an advantage to tenodesis, whereas in the more sedentary population the tenotomy works just as well and is less likely to result in a complication. This new understanding of a potential pain generator is very important in helping patients get the best results after rotator cuff surgery. Our findings will be presented at the upcoming American Orthopaedic Society for Sports Medicine (AOSSM) meeting. The abstract was selected as the top clinical paper for the meeting out of 450 submitted, and orthopedic surgeon Jocelyn Wittstein will be presented the Aircast Clinical Science Award for this work. New techniques The most challenging treatment problem in the shoulder has traditionally been the massive rotator cuff tear. Traditional repair has been met with inconsistent results and many of the tears are, frankly, irreparable. Two new innovations have changed the prognosis in this situation. The first is an understanding of the “suspension bridge” theory of how the rotator cuff works. In the case of a massive tear, in which the tissue is pulled all of the way back past the socket, the bands of remaining tissue in the front and the back have lost tension and cannot serve to center the ball in the socket. Orthopedic surgeon Stephen S. Burkhart of the San Antonio Orthopaedic Group has demonstrated that these bands can be retensioned by arthroscopic surgery in a form of partial repair. This surgery has been
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JULY 2010
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Radiology
Imaging’s Role Increases as
Arthritis Diagnosis & Treatment Advances
By Charles V. Pope, M.D.
Today we no longer have to sit by as these diseases progress; we can help prevent many of them and improve the treatment of many others.
T
Perhaps one of our most important roles is the contribution magnetic resonance imaging (MRI) makes, by virtue of its extreme sensitivity, for patients with systemic arthropathies, such as rheumatoid arthritis, systemic lupus erythematosus, psoriatic arthritis and ankylosing spondylitis. MRI is the most accurate imaging tool available in detecting active erosive/inflammatory changes. Current treatments for arthritis have changed significantly. Drugs such as Enbrel used to halt systemic disease represent a significant improvement over prior therapies. Unfortunately, serious side effects exist and the drugs are expensive. Therefore, it is important to confirm the presence and extent of disease, as well as have a sensitive tool to exclude progression and/or response. Certainly conventional imaging has played an important role and continues to do so. However, there is no doubt that MRI provides the most comprehensive baseline and, when needed, will best determine response.
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The Triangle Physician
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here is much good news concerning care for patients with arthritis and arthropathies, and radiology’s role is expanding in support of these advances. Today, imaging helps identify causes of pain, provides pain relief, improves the accuracy of surgery and is vital in evaluating the progress of patients undergoing promising new drug treatments. Power of MRI is tapped when cause is in question MRI has many other roles as well. A common clinical complaint is low back/radiating pain or hip/groin pain. Conventional radiographic images can confirm a diagnosis of degenerative hip disease in many of these patients. Unfortunately, a number of patients have no clear-cut cause of pain on initial evaluation. For that subset of individuals, MRI can provide an enormous amount of information. A number of diseases can be present without clear findings on physical exam or initial radiographs. These include avascular necrosis, tendonosis, insufficiency fractures or tumor replacement. Also, in the patient with known trauma and suspected hip fracture, MRI can provide an accurate diagnosis when plain films are normal and preclude the sequela of delayed diagnosis. Prompt intervention will result in optimizing treatment, even in the worst-case scenario of tumor.
For the physician whose patient complains of insidious hip pain, an MRI can provide an accurate diagnosis that cannot be achieved with conventional images, especially when the true cause of the pain has nothing to do with the bones. Gluteal tendonosis has largely been a clinical diagnosis in the past. It can be particularly debilitating, often with a nocturnal component. The clinical presentation, however, is often atypical. This process is common in females in their late 40s and 50s. The patient may note hip pain, but may also have a lower back pain with a “pseudoradicular” component or groin pain. Often lumbar disc disease is a mistaken initial diagnosis. The findings on pelvic or hip MRI can be striking. In addition to making a diagnosis, the role of imaging in gluteal tendonosis (frequently associated with trochanteric bursitis and often called the rotator cuff of the hip) can be therapeutic. In patients who fail oral anti-
Musculoskeletal radiologist Charles Pope is founder of Wake Radiology’s musculoskeletal imaging section and credited with raising the bar in sports imaging since joining Wake Radiology in 1986. A native of Mooresville, N.C., Dr. Pope earned his medical degree from the University of North Carolina School of Medicine. He served as chief resident in diagnostic radiology at Duke University Medical Center. He holds a certification in diagnostic radiology from the American Board of Radiology. He also is a member of the American Roentgen Ray Society, the American College of Radiology and the North Carolina Medical Society.
can provide a high level of comfort in that many of the worrisome causes of pain have been eliminated and may allow patients to tolerate the pain in a more reassured fashion. Although MRI is a fantastic tool, it is not always the best imaging examination for a patient. I spend a significant amount of time talking to doctors and patients, explaining why an MRI may not help in certain instances.
inflammatory treatment and who may lack usual anatomic landmarks necessary for injections on a clinical basis, ultrasound or fluoroscopic-guided steroid injections can provide dramatic relief.
Image-guided injections play therapeutic and diagnostic roles We have other valuable modalities to help patients, and one that is playing an increasingly greater role is fluoroscopicguided intra-articular injection of long-acting corticosteroids for patients suffering from post-traumatic osteoarthritis and other degenerative arthropathies. For joints that are deep or difficult to approach, such as the hip or foot, we can provide the necessary precision to ensure the injection is effective.
Finally, imaging may not always provide a diagnosis or cause of the patient’s symptoms. However, in those with long-standing pain, it
In addition to therapeutic injections, imageguided joint injections can also be diagnostic. For those who have failed conservative
treatment of an arthritic joint, surgical fusion may be a valid option. Obviously, if one is to have a successful outcome, the correct joint must be fused. In complex cases, such as the foot where there are numerous small joints, a diagnostic injection can be performed. After using fluoroscopy to localize the joint suspected, contrast is injected to document the location. Subsequently, either anesthetic and/or corticosteroid is infused. Pain relief with this type of injection can be a positive predictor for patients who are more likely to have a successful operative outcome. It’s good to see developments in radiology working alongside the exciting advances in the diagnosis and treatment of arthritis and arthropathies. Today we no longer have to sit by as these diseases progress; we can help prevent many of them and improve the treatment of many others. Improvements in technology have impacted radiology as much as, if not more than, any other field of medicine.
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JULY 2010
29
Women’s Health
New Drug and IUD Offer Improved Treatment Options for Heavy Bleeding By Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G
H
eavy menstrual bleeding (HMB) impacts up to 25 percent of reproductive-aged women. Two important aspects of management of heavy periods are understanding why it occurs and giving comprehensive options for treatment. Causation of HMB includes gynecologic (fibroids or endometrial polyps), hematologic (von Willebrand disease or platelet dysfunction), infection (endometritis) and iatrogenic (copper intrauterine device), among others. Treatment based on cause will improve results. This article focuses on two of the newer options for treatment, specifically a new medication that was highlighted at the American College of Obstetricians and Gynecologists (ACOG) annual clinical meeting in San Francisco in May and a medicated intrauterine system. I have been fortunate enough to be the lead principal investigator for the novel medication Lysteda®, which is tranexamic acid (TA). The other new option for HMB treatment is the Mirena®, or the levonorgestrel
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The Triangle Physician
Health care providers should make sure the underlying cause of heavy menstrual bleeding is determined (or considered) and a comprehensive approach to treatment is presented to women. intrauterine system. Both HMB treatment options are highly effective and help reduce bleeding dramatically. Prescribing information on Lysteda® is given at www.lysteda.com and details on the ACOG meeting presentations can be found at http:// www.medscape.com/viewarticle/722643. I will share some related highlights here. Tranexamic acid reduces bleeding by 50 percent Clinical study findings on quality of life showed improved social and leisure activities in women taking tranexamic acid compared to a placebo. The improvement was dose dependent, so women taking 3.9 g/day had the greatest benefit. Tranexamic acid was developed over four decades ago in Japan and is used worldwide. It is a synthetic derivative of the amino acid
lysine and works through reversibly blocking the lysine-binding sites on plasminogen. This then inhibits the interaction of plasminogen and plasmin on the surface of fibrin. Thus, the fibrin clot is more stable. There is a plethora of evidence showing that women with HMB have more fibrinolysis, likely through higher tPA (tissue plasminogen activator). Importantly, there is no evidence to show that TA, or Lysteda®, causes clots to form elsewhere. This is based on more than 40 years of TA use, as well as no occurrence of blood clots in the clinical trials here in the United States. Using Lysteda® with a combined oral contraception (COC), which is known to increase the risk for blood clots, however, is not recommended. Often COCs are used to treat heavy periods – but these must be taken daily and the amount of reduction in
After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she co-founded and served as the director of gynecology for the Women’s Hemostasis and Thombosis Clinic. She left her academic position in 2007 to begin Carolina Women’s Research and Wellness Center, and to become founder and chair of the Ob/Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head the Women’s Wellness Clinic, the private practice associated with CWRWC. Women’s Wellness Clinic welcomes referrals for management of heavy menstrual bleeding. Call (919) 251-9223 or visit www.cwrwc.com.
bleeding is not as great compared to Lysteda®. My review of evidence shows that COCs reduce bleeding about 30-40 percent compared to about 50 percent with tranexamic acid. Other information regarding Lysteda® is that it is non-hormonal and used only during the days of heavy bleeding (up to five days). When a woman is bleeding heavily, she is motivated to take a medication – and this medication works quickly, so the benefit helps her remember to take the other pills. The 3.9 g/day dose is taken as two pills (each 650 mg) three times daily. The tablets should not be chewed and the most common side effects include headache, abdominal discomfort, menstrual discomfort, diarrhea and nausea.
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Levonorgestrel IUD stops periods in 40 percent The other treatment for HMB that is exciting is the Mirena® levonorgestrel intrauterine system (LNG-IUS). This small device is placed within the uterine cavity for up to five years and releases about 20 mcg/day of levonorgestrel (progestin). The Food and Drug Administration approved its use for treatment of HMB in October 2009. Advantages with LNG-IUS are that there is no user dependence – patients don’t have to do anything – and up to 40 percent will completely stop having a period the second year after placement. The other indication is contraception. So in women who desire contraception, I strongly advise them to consider LNG-IUS. I have been surprised that the intrauterine device (IUD) is not used more in the United States, but this relates to the history of the IUD and the older devices (Dalkon Shield), which caused pelvic inflammatory disease (PID). The LNG-IUS does not cause PID, and is safe and effective for heavy periods. As mentioned earlier, health care providers should make sure the underlying cause of HMB is determined (or considered) and a comprehensive approach to treatment is presented to women. This comprehensive approach includes medication (hormones and tranexamic acid), the levonorgestrel intrauterine system and surgery (e.g. hysterectomy, but also alternatives to hysterectomy, such as endometrial ablation).
JULY 2010
31
Pain Management
By Anne H. Calhoun, M.D.
Headache
Specialty Clinics M
igraine affects about 36 million Americans, with women accounting for three-quarters of that figure. Whereas its annual cost – in terms of treatment and lost productivity – is about $20 billion, the bulk of migraine’s impact is surely borne by its most profound sufferers, those with chronic migraine (CM).
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increased percentage of headaches that are present on awakening. Additionally, studies show that 70 percent of CM patients are overusing acute medications, resulting in so-called “rebound headaches,” mediated through 5-HT2A receptors. And finally, CM has a bi-directional comorbidity with anxiety disorder.
Early recognition and appropriate intervention can be associated with better outcomes for this disabling – and not uncommon – headache disorder. CM is one of four recognized chronic daily headache disorders. It gradually evolves from episodic migraine, undergoing a transition that is often quite subtle, as milder headaches or neck tension begin to fill the days between migraine attacks. The diagnosis of CM requires headaches on 15 days or more a month over a course of at least three months. Additionally – if left untreated – eight or more of those days would have reached criteria for migraine. Researchers at the Carolina Headache Institute (CHI) in Chapel Hill have been influential in characterizing migraine’s chronification process. In many patients, transition is marked by an increasing prevalence of neck tension that radiates forward to a frontal or retro-orbital position when pain intensifies. We have found that the presence of neck pain – even when it occurs on the day preceding migraine treatment – has a detrimental impact on treatment outcome. When migraine becomes chronic, it also is marked by non-restorative sleep and by an
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The Triangle Physician
CM patients often become trapped in a vicious cycle of pain catastophizing, insomnia and medication rebound. If they receive opioids, migraine attacks can escalate through opioidinduced hyperalgesia, increasing pain perception for months afterwards. CHI researchers have also shown that migraineurs (migraine sufferers) who take opioids tend to be greater consumers of outpatient clinic resources – accounting for a larger share of clinic phone calls and a reputation for being demanding and timeconsuming – factors which can interfere with optimal treatment. Specialty clinics offer advanced expertise Headache specialty clinics are uniquely equipped to treat individuals with CM. These centers generally employ a multidisciplinary approach. At CHI, our team includes neurologists with subspecialty boards in pain management, a headache medicine specialist who is also an authority on estrogen’s effects on the central nervous system, and a clinical neuropsychologist with a fellowship in traumatic brain injuries. Additionally, headache centers frequently have the availability of infusion suites to provide monitored intravenous therapy to break sustained migraine attacks or to withdraw
Dr. Anne Calhoun is a co-founder of the distinguished Carolina Headache Institute in Chapel Hill, along with partners Kevin A. Kahn, M.D.; Alan G. Finkel, M.D., F.A.A.N., F.A.H.S.; and Sutapa Ford, Ph.D. Dr. Calhoun and her partners have been honored with many top awards in headache medicine and have authored more than a hundred articles and textbook chapters. An authority on the effects of estrogen on the central nervous system, Dr. Calhoun was invited faculty at the most recent International Headache Congress. For more information call (919) 942-4424 or visit www.carolinaheadacheinstitute.com.
patients from overused medications. Protocols that once required hospital stays can now be received as outpatients in these suites, where the same medications are administered over the same duration, typically three to five days. Protocols vary but often consist of dihydroergotamine, magnesium, antiepileptics and/or anti-nauseants. Sometimes steroids or antipsychotics also are added. Other out-patient procedures available at headache specialty clinics include triggerpoint injections, nerve blocks and neurolytic therapy. Women with particularly severe menstrual attacks may benefit from tailored hormonal therapies that nullify those triggers. And psychological interventions may include mind-body techniques, relaxation and cognitive therapy. While there is no cure for migraine, treatment focuses on reverting CM back to episodic attacks. Early recognition and appropriate intervention can be associated with better outcomes for this disabling – and not uncommon – headache disorder.
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