Monday, May 11, 2015

Do I need an MRI before I see an Orthopedic Surgeon?

The short answer to this is no.  Well, not usually.  MRIs are a very useful tool in orthopedic surgery, and we have come to depend on them for many facets of diagnosis and surgical planning.

There is commonly the thought that obtaining an MRI before your visit will "Save a step" in getting you better.  What I frequently tell patients is that "I treat people, not MRIs".  What that means is that I am far more interested in what you have to say and what your knee feels like, than what an MRI can tell me about your knee.  So, getting an MRI may be necessary at some point, but may not be necessary.

MRIs also come in different varieties and I order special MRI sequences depending on the question I want answered.  For example, if I suspect a SLAP tear in a young pitcher I will order dye injected into the shoulder joint prior to the MRI, making it an MR arthrogram.  I will also request that their arm be placed in a certain position.  I will not typically ask for an MR arthrogam in a 50 year old carpenter with shoulder pain in which I suspect a rotator cuff tear.  If a patient has had previous surgery, metallic anchors would make an MRI useless because the metal would interfere with the magnets and the picture would be blurry.  In that case, a CAT scan with dye injected into the shoulder would be a more useful way to see the structure of the shoulder.

The final reason not to try to get an MRI before you see me is that most primary care doctors have difficulty convincing your insurance that they should pay for an MRI.  Their staff has to argue and struggle with the insurance companies to get the MRI "pre-approved".  Frequently, despite all of their efforts, the insurance companies feel that the MRI is not warranted.  Our office, on the other hand has a near flawless record of getting these approved.  Part of this is my wonderful staff and their familiarity with the nuances of MRI scheduling and part of it is that for better or worse, my recommendation as a specialist carries more weight with the insurance companies than your PCP.  So, let us do the work for you and save yourself the aggravation.

- J. Fallon

Sunday, May 10, 2015

What Kind of Music Do You Play in the Operating Room?

I was recently asked this by one of my high-school aged patients.  My response was, "It depends... what do you want to listen to while I operate on you?".  So we spent the next 45 minutes exploring the K-Pop station on Pandora. 
I love music.  I grew up playing the guitar (poorly) and I recently returned to learning the guitar (still struggling).  I believe in the healing and soothing properties of music.  I believe in the common language of a well done melody.  There are some that believe that music is a distraction in the operating room and there is no place for it.  I had a mentor the would reference the sound of the electronic heart monitor (a hopefully constant beep…beep... beep) as music to his ears and the only thing he wanted to listen to.  While I respect him immensely and his perspective, in my OR music has a definite role.  There are times for ultimate focus and silence, but the reality is that the OR is an inherently tense environment filled with people of diverse backgrounds that have to work together quickly, efficiently and precisely.  Anything that we can do to decrease the anxiety and stress level, makes for a more effective team and better surgery. There was actually a study in the Journal of the American Medical Association that demonstrated improved relaxation and motor skills of surgeons listening to music of their choosing.  
Some days require something mellow like Jack Johnson or Big Head Todd.  Other days need a kick in the pants and we get Ja Rule.  Most days end with AC/DC and you don’t want to hear my OR Jazz mix… that’s a bad day.   Music is good for me, it is good for my team and it also good for the patient.  Playing melodies for patients has been shown to decrease anxiety levels and heart rates in perioperative patients.  

Fun fact:  Apollo was the god of Music and Healing

Monday, May 4, 2015

The Biology of ACL Reconstruction and Regeneration

One of the best examples of the wonders of modern medicine is Anterior Cruciate Ligament reconstruction.  Because the body is unable to heal the ACL on its own, it requires reconstruction in order to restore normal function to the knee.  The process of ACL regeneration relies heavily on the biology of your knee.
When I reconstruct your ACL, I take a tendon, either from an organ donor or from a different part of your body, then place it where I want a ligament to grow.  Your body uses this tendon as a scaffolding to regenerate a new anterior cruciate ligament.  This process occurs and 3 phases.  The initial phase is characterized by necrosis or cell death.  During the first 4 weeks after surgery, your body tears down all of the living cells in the graft, leaving only nonliving tissue as a blueprint for the final ligament.  The second portion of the regeneration process is called the proliferation phase.  This usually occurs in the second and third month after surgery.  This is characterized by influx in your own body’s cells into the remaining scaffolding.  The scaffolding also undergoes changes that cause significant weakness in the graft.  6-8 weeks after surgery is typically thought of as the weakest point and the time where of the structure of the graft needs the most protection.  The final phase, the ligamentization phase begins about 3 months after surgery.  During this time, the graft is slowly and steadily getting stronger and becoming more like the original ACL.  There is no clear end point however there is plenty of evidence suggesting that the graft will continue to mature over the following year.