The OA Update 3

The OA Update is published by Oser-Bentley Custom Publishers, LLC, a division of Oser Communications Group, Inc., 1877 N. Kolb Road, Tucson, AZ 85715. Phone (972) 687-9035 or (520) 721-1300, fax (520) 721-6300, www.oser.com.Oser-Bentley Custom Publishers, LLC specializes in creating and publishing custom magazines. Inquiries: Tina Bentley, tina@oser-bentley.com. Editorial comments: Karrie Welborn, karrie_w@oser.com. Please call or fax for a newsubscription, change of address, or single copy. This publication may not be reproduced in part or in whole without the express written permission of Oser-Bentley Custom Publishers, LLC. To advertise in an upcoming issue of thispublication, please contact us at (972) 687-9035 or (520) 721-1300 or visit us on the Web at www.oser-bentley.com. July 2009

6. Conditioning for theSuperior PitcherDebunking the distance running mythThe purpose of conditioning activities for pitchers should be to build a superiorathlete. Stan Skolfield, ATC, CSCS, debunksthe myth that distance running results in a better pitcher.

8. Finding Relief for Your Arthritic ThumbDiagnosing and treating thumb arthritisThumb arthritis develops when the cartilagecovering the bones wears out. Dr. Sacha D.Matthews provides an overview of thumbarthritis and its multiple treatment options.

10.Why a Second Opinion?Don’t hesitate to ask for another opinionThere are frequently multiple ways to treat a given condition and second opinions can be helpful and reassuring.Patients should never be afraid to ask for a second opinion.

13.Try a TriTrio of activities leads to better fitness healthThere is no better way to get in shape thanto try a triathlon. Dr. Eric Hoffman offerstips for how to start triathlon training.

16. Experience inOutpatient ShoulderSurgerySurgical advancements offer more benefits to patientsMost shoulder procedures are now done onan outpatient basis thanks to advancementsin arthroscopic techniques and safeoutpatient perioperative pain management.

20. Understanding Sports-Related ConcussionsFrequently asked questions about concussionsThe best way to prevent difficulties with a concussion is to manage the injury properlywhen it does occur. Dr. Lucien R. Ouelletteanswers some of the most common questionsregarding sports-related concussions.

FEATURESIn This Issue

DEPARTMENTS 5. OA in Motion: What’s New? News and notes on people, places and happenings in the organization.

4 The OA Update

Opening RemarksThe physicians and staff of OA Centers for Orthopaedics (OA) welcome you to the latest issue

of The OA Update. In publishing this magazine, OA hopes to create an opportunity for educatingpatients and their families about various orthopaedic conditions, preventative strategies for avoidinginjury and treatment options should an orthopaedic problem arise. We believe that offeringinformation on new and evolving techniques and treatments enhances our patients’ ability toparticipate in making educated treatment decisions.

In this issue, we’ve included information ranging from bone health to hip arthroscopy topreparing for your first triathlon. We hope you find this issue informative and helpful, and welcomeany suggestions for future publications. We’ve already heard from some of you and are appreciativeof your comments and feedback!

Sincerely,The Physicians at OA Centers for Orthopaedics

OA is the premier orthopaedic practice in Maine.Our 23 highly specialized physicians are experi-enced in the latest techniques and innovations. OAspecialty centers include sports medicine; handsurgery; joint reconstruction of the hip, knee andshoulder; foot and ankle surgery; and complex frac-ture treatment. OA—Experience in motion!

The information contained in this publication is notintended to replace a physician’s professionalassessment. Please consult your physician on mat-ters related to your personal health.

OA Centers for Orthopaedics33 Sewall St.Portland, Maine 04102(207) 828-2100 • (207) 828-2190 faxinfo@orthoassociates.com

John Wipfler Chief Executive Officer

Satellite Locations:

Saco Office15 Lund RoadSaco, ME 04072(207) 282-4210

Windham Office4A Commons Ave. Rte. 302Windham, ME 04062(207) 893-1738

Specialty CentersJoint Replacement CenterOrthopaedic Trauma CenterHand CenterFoot and Ankle CenterSports Medicine CenterSpine CenterMRI CenterOrthopaedic Surgery CenterPhysical Therapy CenterPerformance Center

The OA Update 5

OA in MotionAAAHC Best PerformerOA again participated in a performance measurementinitiative evaluating best practices for kneearthroscopy with menisectomy, with the purpose ofcollecting data on key processes and outcomes for thisprocedure. The information obtained is used forclinical quality improvement efforts and to provideorganizations with alternatives in practice to providea better value in quality and cost to their patients.

The Institute for Quality Improvement, anot-for-profit subsidiary of the AccreditationAssociation for Ambulatory Health Care(AAAHC), identified OA’s Surgery Center as a“Best Performer” in the following categories:• Lowest Pre-procedure

(No. 1 rank, top 3 percent)• Lowest Procedure Time

(No. 1 rank, top 3 percent)

OA Sports Center Open HouseOA Centers for Orthopaedics and MHG IceCentre have joined together to create a fullyintegrated state-of-the-art facility, which includesOA’s orthopaedic and sports medicine clinic, OAPhysical Therapy Center, the OA PerformanceCenter featuring the Parisi Speed School and abiomechanical research center, as well as a year-round indoor ice arena and home of the PortlandJunior Pirates. An open house celebration was heldin March, and the event was attended by 2,000guests including Governor John Baldacci and BillParisi, founder of Parisi Speed School.

Dr. Brown as “Godfather”This past April, OA's Dr. Douglas Brown wastraveling with the fellowship program of theAmerican Orthopaedic Society for Sports Medicineto Japan, South Korea, Taiwan, Thailand andSingapore. The traveling fellowship program is anannual scientific and cultural exchange amongorthopaedic sports medicine physicians in NorthAmerica, Europe, Latin America and the PacificRim. Three fellows are selected to visit foreign sportsmedicine centers for three weeks and areaccompanied by a “Godparent”—a well-knownsenior orthopaedic sports medicine specialistselected by the president of the national sportsmedicine organization. The Godparent for this year’strip was our very own Dr. Brown. This is an honorfor Dr. Brown, and the OA Team is proud of him!

Dr. Charbonneau receives 2008 Caregiver of the Year awardIn recognition of her extraordinary commitmentto the delivery of care to patients and theirfamilies, Dr. Elissa Charbonneau was presentedwith New England Rehabilitation Hospital(NERH) of Portland’s Caregiver of the Yearaward. Dr. Charbonneau shares her time betweenNERH and OA Spine Center. Congratulationsto Dr. Charbonneau!

Relocation of Satellite Office ServicesAs part of our commitment to providing the best inintegrated orthopaedic care and treatment for our

patients, OA Centers for Orthopaedics hasrelocated clinical services from ourScarborough and Yarmouth locations tothe new Saco location at 15 Lund Road.Along with the Saco location, OA’sphysicians will continue to provide servicesat our other locations in Portland andWindham. While appointments with all ofOA’s physicians are not available at everylocation, our appointment specialists willwork with the individual to schedule withthe appropriate physician at the mostconvenient location.

Joint Lecture SeriesThe physicians from the OA Joint ReplacementCenter are offering educational lectures oncontemporary options in total joint surgery. Thesesessions will highlight leading options for fastrecovery, durable results, high activity and lesspain after joint replacement surgery. For moreinformation, email jtilton@orthoassociates.comor call (207) 710-5509.

Lecture Schedule (6:30 p.m.–7:30 p.m.)• May 6: What is the Right Type of Hip

Replacement for You?Brian McGrory, MD

• May 20: Your Total Knee Replacement OptionsSteve Kelly, MD

• June 3: The 24-Hour Minimally Invasive TotalHip ReplacementGeorge Babikian, MD

• June 17: Minimally Invasive (MIS) KneesPeter Guay, DO

• July 1: 5000 Total Knee ReplacementsMichael Becker, MD

• July 15: Shoulder Replacement SurgeryDonald Endrizzi, MD

OA as a Community PartnerThe 18 staff members who constitute the OAEvents Committee coordinate programs andevents to encourage socializing across theorganization and get employees involved in thecommunity. In the past year, OA physicians andstaff have generously supported the following localorganizations through this committee’s efforts:• The Root Cellar (Portland) and People’s

Regional Opportunity Program (South Portland):Thanksgiving dinner donations for three families

• Salvation Army adopt-a-family program(Portland): Christmas family dinner and giftdonations for four families

• Animal Refuge League of Greater Portland: In-kind donations to support the animals at theshelter and group project work at the shelter

• American Red Cross: Blood Drive at OA• United Way of Greater Portland: Annual

donation campaign

6 The OA Update

Warmer weather has returned, and thatmeans baseball season is underway. Boys andgirls will be running around throwingbaseballs and softballs as well as swinging thebat. Coaches will also be busy preparing theirathletes for the demands of the season. Overthe years the training methods for developingthe superior ballplayer have changed, yetmany coaches are still doing things the “oldway” because that is the way they were taughtwhen they played competitive sports. I wantto share with you the biggest training myth

out in the game today in hopes that you willnot make the same mistake with your athlete.

The most common training myth thatbaseball coaches and trainers fall into is: Pitchersshould run long or poles to get themselves in greatshape and recover from training.

The common view of most baseballcoaches is that distance running helps pitchersby building strength in their legs, enhancingtheir endurance, developing mental toughnessand improving their overall physical fitness. Icompletely disagree—when was the last time

you saw a marathoner throw at 95 mph?Not only is this far from the best use

of training time, it is proven to becounterproductive. It is one of the worstthings you can do to train an explosiveathlete. After all, pitching is an explosiveaction and to be good at it requires atremendous amount of recruitment anddevelopment of fast twitch muscle fiber.

Think about it. If you wanted tooptimally train an athlete for an activity thatinvolves one to nine sets (innings) of 15–20

Conditioning for theSuperior PitcherBy Stan Skolfield, ATC, CSCS

full body explosions (pitches) lasting onesecond and then 20 seconds of recovery, thena 15-minute block of rest recovery betweensets, does running slowly for two to three milessound like the best method for creating a moreexplosive athlete? Would you train a 100 or200 meter sprinter by running long distance?Of course not. Don’t do it with pitchers either!

The purpose of conditioning activities forpitchers should be to build a superior athlete.Help them become more durable, effective andexplosive. Running long distance is a giantwaste of training time, recruits the wrongenergy system (aerobic vs. anaerobic), recruitsthe wrong muscle fiber type (slow twitch vs.fast twitch) and adds an unnecessary andrepetitive stress to the hip, knee, ankle andfoot. Distance running conditions ballplayersto trot instead of bounce.

For those of you who want to argue thatit builds mental toughness, I beg to differ.Running at a very slow pace for a prolongedperiod of time is a great way to build mentaltoughness if you’re a very weak-mindedindividual. If you want to better conditionyour pitchers, have them do 10–15 by 40- or60-yard sprints. You could also have them useladders, do agility drills, perform series ofbody weight exercises with short rest intervals.The possibilities are endless as long as theactivity is brief and intense. I promise you, ifyou program the workout correctly then bythe 8th or 9th rep of 60-yard sprints theathletes will be sufficiently challengedmentally. Compared to that workout, running10 poles would seem like a vacation!

Pitchers should develop a great base of totalbody strength in the weight room. Developlower body strength with squats, lunges, singleleg squats and step ups. Promote great corestrength through stabilization exercises (planks,side planks, bridges) and rather than crunchingmovements. Finally, promoting upper bodystrength with chin ups, rows and push upvariations is a great way to lay the foundationneeded to develop a more explosive athlete.

So I challenge you to change yourmindset when it comes to conditioning yourballplayers. Some of the points I have mademay go against the grain of old schoolbaseball, but the game has changed and so has

The OA Update 7

the athleticism it takes to be a superior athlete.I will take an athlete who has developed himor herself to be much more explosive over anathlete who has a high VO2 max any day!

Stan Skolfield is a Certified Athletic Trainer(ATC) through the National Athletic TrainersAssociation (NATA) as well as a Certified

Strength and Conditioning Specialist (CSCS)through the National Strength and ConditioningAssociation (NSCA). He has been involved withthe training, nutrition and rehabilitation ofathletes at multiple levels. He has worked for theBoston Red Sox, providing injury prevention andrehabilitation for in-season teams. Stan is theManager for the OA Performance Center.

8 The OA Update

Thumb arthritis involves the joint at the base ofthe thumb, the carpometacarpal (CMC) joint.This joint is made of two bones—the trapeziumand the metacarpal. Thumb arthritis developswhen the cartilage covering the bones wears out.As a result, the bones rub together causing pain,swelling and stiffness. Anyone can developthumb arthritis, but it is seen more often inwomen. It is more common as we age. Patientsexperience an achy pain, which can wake themup, and which is worse with pinching or grippingsuch as opening jars. In advanced cases, patientscan develop weakness and a grinding sensationwith gripping. The thumb may appear deformedwith a “bump” at its base. The diagnosis ofthumb arthritis is made by a trained health careprofessional. A history of pain in the base of thethumb, worse with pinching, is suggestive of thediagnosis. On physical exam, the CMC joint istender to touch and twisting causes a painfulgrinding. X-rays can confirm the diagnosis.

Treatment begins with avoiding pinchingand gripping, heat in the morning to loosen thejoint, and ice at night to decrease swelling.

Mechanical jar openers and tools with largerhandles can be quite helpful. Splints thatsupport the thumb reduce pain. Cortisoneinjections can lessen the pain for a time. If thesethings fail, then surgery may be considered. Thetype of surgery is determined by the treatingsurgeon. Most commonly, surgery involvesfusion of the CMC joint, where the metacarpaland trapezium are joined together, or aLigament Reconstruction Tendon InterpositionArthroplasty (LRTIA), where the trapezium isremoved and a tendon is used to rebuild theligaments with the remaining tendon placed as

a spacer. These procedures are successful inincreasing motion and strength, whileeliminating pain. Don’t let thumb arthritis slowyou down—solutions are available.

Dr. Matthews is a hand surgeon in the OA HandCenter, which provides comprehensive coverage forthe diagnosis, treatment and rehabilitation of alltypes of hand and wrist problems. He is a fellow ofthe American Academy of Orthopaedic Surgeonsand a member of the American Society for Surgeryof the Hand. He also has a Certificate of AddedQualification in Hand Surgery.

Finding Relief for Your Arthritic ThumbBy Sacha D. Matthews, MD

Arthritic Carpometacarpal Joint. Status-Post Carpometacarpal Suspension Arthoplasty.

The OA Update 9

10 The OA Update

In the practice of medicine, there arefrequently multiple ways to treat a givencondition. In many cases, there are differentrecommendations and treatments that can beoffered for the same orthopaedic problem.Practice styles can vary considerably, evenwithin a group practice, depending on whereand with whom the physicians trained. Whenfaced with the decision for proceeding withsurgery, many patients feel that anotheropinion will be beneficial in verifying that adiagnosis is correct and the treatment plan isreasonable. In some cases, a patient may havealready initiated treatment with a provider, butnot be progressing as expected. Again, anotheropinion may be reassuring or provide anotheroption not previously considered. A patient’sphysician may also request a second opinionfrom another specialist to assist in providingcare to that patient. Finally, as is common inwork-related injuries, an insurance providermay request a confirmatory second opinion tobe sure an employee’s care is reasonable.

The physicians at OA Centers forOrthopaedics receive a number of requestsfor second opinions. When requesting anappointment for a second opinion, it isimportant to provide the physician with a fullsummary of prior evaluations, diagnostic testsand treatments. While some patients may feelthat having access to this information may

negatively impact the new physician’s evaluationand treatment recommendations, this is simplynot the case. This information is essential, notonly to provide the physician with a more“complete” journal of the patient’s situation, butalso to minimize the need to duplicate studiesand incur unnecessary medical costs. In manycases, the patient will be asked to gatherinformation and provide it to the physician heor she is requesting to see prior to theappointment. This will expedite the schedulingprocess and make for a more comprehensiveevaluation process.

While another opinion can be helpful insome situations, multiple opinions can be veryconfusing and counterproductive to a patient’srecovery. To help with making the decisionto pursue a second opinion, the patient maybenefit from having a discussion with hisor her primary care physician. The primarycare physician may provide insight to therecommended treatment plan and guide youin seeking another opinion, or address yourconcerns enough to proceed without one.Remember that physicians may in fact havedifferent opinions on the treatment of aproblem, and while it is appropriate to explorethose differences with the providers, don’texpect to reconcile the differences. The goal ofanother opinion should be to confirm carerecommendations or to learn more about other

options. In the end, you may need to make achoice based on the information provided.

Finally, patients can sometimes be reticentto ask for a second opinion. This should neverbe the case. Physicians themselves request suchconsultations and realize it is an importantpart of medical practice. So if you are not sureabout your treatment course or results, don’thesitate to ask for another opinion.

Dr. Thomas Murray Jr. practices sports med-icine and arthroscopic surgery at OA Centersfor Orthopaedics.

Why a Second Opinion?By Thomas F. Murray Jr., MD

Top 10 Reasons for a Second OpinionThe diagnosis or treatment seems to be in question

Treatment fails to provide relief

Unusual or complicated procedure is recommended

Out-of-work time or expense seems unreasonable

Recovery seems prolonged, delayed or incomplete

Your physician has little or no experience with a given procedure

A complication or mishap has occurred

A patient is told “nothing else can be done”

Physician-patient communication problems

Anytime you think it might help you

The OA Update 11

12 The OA Update

The OA Update 13

There is no better way to get in shape than totry a triathlon. The combination of swimming,biking and running leads to excellent upperand lower body fitness health. Running helpsboost cardio health, speed and vitality. Bikingboosts endurance with low impact. Andswimming works the upper body, core andhelps to “stretch out.”

First-time triathletes usually target a sprintdistance race. This involves a short pool swimor an open swim of approximately 1/3 mile,biking 12–14 miles and ends with a 5K run.Anyone can complete a sprint distance race, andgetting started is easy.

Start by signing up for an event. This willgive you goal-oriented exercise motivation.Second, find an individual or group with whichto train. Having a “buddy” or group of friendsto work out with can make this a fun activitythat you look forward to. Third, begin work onyour fitness in a well-thought out manner givenyour current fitness level.

Anyone in reasonable shape can getready in as little as six to eight weeks. It ispreferable to prepare over a longer period oftime, however, and most athletes end updoing year-round exercise to maintain their“tri” fitness. Some athletes prefer moreguidance and supervision as part of a

training program so that they can meettheir performance goals without injury.

OA Performance Center in Saco offersthe Parisi speed and strength program thatcan serve as an excellent base for triathloncompetition/participation. OA can provideyou with an excellent bike fit and gaitanalysis to ensure that the “foundation” issound. For the more serious triathletes, thereis a human performance lab offeringphysiologic testing, lactate threshold, VO2max and more. In the future, OA will beexpanding their triathletes offerings toinclude endurance programs and camps.

Peak Performance Multisport in Portlandoffers the “Nor’Easters,” an inexpensive clubmembership that allows participation inorganized group workouts, usually with aguide or coach. Peak Performance also offersindividual coaching and equipment adviceabout needs for your first race—wetsuit,

goggles, bicycle, apparel, helmet and shoes.This doesn’t have to be expensive; most first-timers will use a bike they already have orborrow one.

The event itself is a blast. It is a funatmosphere with a very unassuming crowd. Theloudest cheer often goes to the last one out ofthe water. So go ahead and take the challenge!Sign up for a “tri.” You won’t regret it. Maybeyou will catch the “tri-bug” and keep it as partof your everyday life. Lastly, enjoy your fitness!

Dr. Hoffman practices orthopaedic sports medi-cine with a special interest in arthroscopic treat-ment of knee and shoulder injuries. He is the teamphysician for Falmouth High School, consultantfor other local high schools and Sunday River SkiResort, as well as an instructor for the Maine Med-ical Center Sports Medicine Fellowship Program.He is active in many sports including triathlonsand is a 2007 Ironman Lake Placid finisher.

Try a TriTry a TriBy Eric D. Hoffman, MD

VISIT THESE WEBSITES FOR MORE INFORMATION ABOUT TRIATHLON TRAININGwww.orthoassociates.com www.mypeakmultisport.com

www.tri-maine.com www.trifind.com/me.html

http://beginnertriathlete.com

14 The OA Update

Osteoporosis is a silent disease until a fractureoccurs. The pathology of osteoporosis allowsbones to become weak and brittle, causingthem to fracture with very minor trauma.An estimated 10 million Americans haveosteoporosis and another 34 million are atrisk, making osteoporosis the most commonbone disease, according to the NationalOsteoporosis Foundation. Osteoporoticfractures can heal completely or they may befollowed by chronic pain, disability and evendeath. Hip fractures result in 10 to 20 percentexcess mortality within one year and areassociated with a 2.5 fold increased risk forfurther fractures.

The disease is more commonly associatedwith older women, but osteoporosis canoccur at any age and to both men and women.

Women are four times more likely thanmen to develop osteoporosis, especially withinthe first five to seven years after menopause,when they lose significant bone mass. Riskfactors also include race and ethnicity(Caucasians and Asians are more susceptible),history of broken bones, inactive lifestyle anddiet (low calcium and vitamin D intakes).

It is recommended that all women age65 and older and men age 70 and older bescreened for osteoporosis. Women with anincreased risk for osteoporosis should beginscreening at the time of menopause. Todiagnose osteoporosis or the potential risk forit, the most common procedure is a dualenergy x-ray absorptiometry scan (DXA scan)to measure the bone density of the spine andhips. Alternative methods to measure bone

density are an ultrasound and a quantitativecomputerized tomography (CT) scan. Bonedensity tests measure how many grams ofcalcium and other minerals are packed in asegment of bone, and from that informationthe relative risk of a fragility fracture (definedas a fracture resulting from a fall fromstanding height) can be estimated.

The National Osteoporosis Foundationrecommends five steps to healthy bones andavoiding osteoporosis.• A proper diet, making sure to include the

recommended daily amounts of calciumand vitamin D. The recommended dailyintake of calcium for adult men andwomen is between 1,200 and 1,500milligrams and that of vitamin D is 1000International Units (IU).

The Story Behind OsteoporosisBy Carrie Bui with William Heinz. MD

The Story Behind OsteoporosisBy Carrie Bui with William Heinz, MD

The OA Update 15

• Exercise, especially with a focus on weight-bearing and muscle strengthening exercises.Examples of weight-bearing exercisesinclude jogging, hiking, gardening andweight training. Strength training increasesmuscle mass, leading to better coordinationand balance. Improved coordination andbalance can help prevent falls that canresult in fractures.

• Maintain a healthy lifestyle by avoidingsmoking and excessive alcohol consumption.

• Talk to a healthcare provider to discuss bonehealth, prevention, risk and monitoring.

• Have a bone density test (DXA scan)regularly. A bone density test can warn youof low bone mass and track if bone densityis remaining stable or decreasing.

The effect of osteoporosis is fractures, mostoften in the spine, hips or wrist. Often,osteoporosis is not discovered until a fractureoccurs, but symptoms to note are back painand loss of height with accompanyingstooped posture. A comprehensive osteoporosistreatment program would include maintaininga proper diet, regular exercise and theprevention of falls.

The U.S. Department of Health andHuman Services suggests that the best wayto achieve the required vitamin D intakeis through sunlight. Ten to 15 minutesof sunlight to the hands, arms and face atleast three times a week should offer enoughvitamin D. (Be careful not to overdothe sunlight as it will increase your risk forskin cancer!) This vitamin is necessary forthe absorption of calcium. Recommendedcalcium-rich foods include all dairyproducts, such as yogurt, cheese, milkand ice cream. Also, calcium-fortified

orange juice and broccoli are gooddietary sources of calcium.

To avoid fractures, consider fall preventionstrategies to reduce the risk of falling:• Meet with your doctor to discuss whether

any medications or health conditions areincreasing your fall risk.

• Exercise to improve strength, balance,coordination and flexibility.

• Wear sensible shoes to avoid falls. Tips forsensible shoe buying include proper fitting,non-skid soles and shoes with laces.

• Remove hazards within the home such ascords, boxes or any kind of clutter blockingwalkways. Secure loose rugs, repair any looseflooring immediately and use non-slip matsin the bathroom and shower.

• Create plenty of light through lamps andnight lights to avoid falling or trippingover items that can’t be seen in poorly lightedor dark rooms.

The use of assistive devices can also helpprevent falls. Assistive devices include grabbars mounted inside and just outside theshower or bathtub, a plastic seat placed insidethe shower for sitting down, handrails onboth sides of a stairway and non-slip treadsfor bare wood steps.

The key to understanding osteoporosisis understanding the prevention of it.Prevention of osteoporosis includes a properdiet, with a focus on meeting calcium andvitamin D requirements, exercise, with afocus on weight-bearing exercises and carefulmonitoring later in life.

Dr. William Heinz works in the OA SportsMedicine Center and specializes in the diagnosisand non-surgical treatment of sports-relatedmusculoskeletal injuries. He has interest in bonehealth and is a certified clinical densitometrist.He performs diagnostic interpretations for allbone densitometry scanning performed at OACenters for Orthopaedics.

Am I at increased risk of having osteoporosis? Your chances of developing osteoporosis are greater if you are female and answer “yes” to any of the following questions:

Are you…?Light skinned

Thin or small framed

Approaching or past menopause

Milk intolerant or have a low calcium intake

A cigarette smoker or drink alcohol in excess

Taking thyroid medication or steroid-baseddrugs for asthma, arthritis or cancer

Do you have…?A family history of osteoporosis

Chronic intestinal disorders

A sedentary lifestyle

Speak with your physician if you are concerned about your bone health!

The pathology ofosteoporosis allows bonesto become weak and brittle,causing them to fracturewith very minor trauma.

16 The OA Update

Over the last two decades, shoulder surgery has transformed from alargely inpatient-based practice to a predominantly outpatient series ofprocedures. Although some procedures continue to be inpatient-basedsuch as arthroplasty or open reduction with internal fixation (ORIF),most shoulder procedures are now routinely done on an outpatient basis.Advancements in arthroscopic techniques, with less extensive surgicaldissection, have decreased the overall pain of many procedures tomanageable levels that allow safe outpatient management ofperioperative pain. Economic factors such as decreasing reimbursementfor overnight hospitalization and the availability of outpatient surgicalfacilities contributed to this transition, along with patient demand.

Perioperative pain management remains a crucial part of outpatientsurgery and can seriously impact the patient’s perception of their surgicalexperience. At OA, the team is committed to the highest standards ofoutpatient surgery services that are personal, safe and cost effective. Ourspecialized orthopedic surgeons and our highly trained staff ofexperienced RNs, physician assistants and anesthesiologists (from theSpectrum Medical Group) work together to provide the highest qualitysurgical care available anywhere in the country. This includes workingtogether to develop effective pain management strategies, evaluate howservices are delivered and how patients respond.

Regional anaesthesia refers to blocking the nerve supply to part of

Experience in Outpatient Shoulder SurgeryOA Orthopaedic Surgery Center By Donald Endrizzi, MD; Linda Ruterbories, MS, ANP; Craig Curry, MD and Thomas Murray, MD

The OA Update 17

the body so the patient cannot feel pain in that area. Regional blockshave become an important adjunct to pain management in theshoulder. However, regional blocks are not without risks and costs.Many centers use regional blocks in combination with generalanaesthesia, which can add significantly to the cost of the procedure.The rate of complications varies greatly in the literature, with lowerrates reported as institutional experience increases. Local anaesthesiameans putting local anaesthetic around the affected area to make itpain-free and is often referred to as “freezing” the area. Dr. DonaldEndrizzi, Dr.Thomas Murray and Linda Ruterbories, MS, ANP, of theOrthopaedic Surgery Center at OA and Dr. Craig Curry fromSpectrum Medical Group collaborated in evaluating the effectivenessand benefits of local anaesthesic infiltration (LAI) and generalanesthesia for outpatient shoulder surgery.

From 1998 through 2007 the data on 3,115 patients undergoingoutpatient shoulder surgery was collected prospectively. This includedboth arthroscopic and open surgical procedures performed by twoexperienced shoulder surgeons. The surgical procedures included 757rotator cuff repairs, 404 instability repairs, 996 acromioplasties, 165acromioclavicular joint excisions, 290 SLAP repairs or debridements and503 other shoulder surgeries. Patients were contacted on post-op day oneand assessed by nursing as to any post-operative difficulties or complaints.

It has been the impression of the investigators that generalanaesthesia with local anaesthetic infiltration is a safe and effectivemethod for shoulder surgery. The advantages of this technique includeits low complication rate and acceptance by patients, with a high degreeof patient satisfaction after surgery. No significant complications relatedto local anaesthetic infiltration were noted. There were no seizures orcardiac disturbances related to the anaesthetic infiltration, in contrastwith some rare but significant complications reported with regionalblocks. The cost of local anaesthetic infiltration is low. Regional blockanalgesia is often combined with conscious sedation or generalanaesthesia which can significantly raise the cost of the procedure.

Other alternatives to a regional block exist. Unfortunately there aresome patients and procedures in which local anaesthetic infiltration mightnot be appropriate, such as longer, more extensive surgeries associated withhigher levels of pain with more tissue disruption.

There is a role for regional block in the post-operativemanagement of pain; however, its use as a routine part of shouldersurgery can be questioned. The Orthopaedic Surgery Center team atOA believes that selected surgical cases can be managed just aseffectively with a short-acting general anaesthetic agent and localanaesthetic infiltration, lowering risk to the patient and costs to thepayer, without sacrificing post-operative pain relief.

Dr. Endrizzi specializes in shoulder surgery and is the Medical Directorat OA Orthopaedic Surgery Center (OSC). Dr. Murray specializes insports medicine and arthroscopic surgery at OA Centers for Orthopaedics.Ms. Ruterbories is a nurse practitioner and serves as Director of OSC.Dr. Curry is an anesthesiologist from Spectrum Medical Group and has aspecial interest in regional anesthesia and pain management.

18 The OA Update

Each year more than 7 million people visit theirdoctor with concerns related to hip pain. Formany, the pain is so severe that simple thingslike climbing stairs or bending to tie their shoesare difficult. Some may even have back or groinpain and not realize this pain is actually theresult of a hip condition.

Many patients find pain relief through anti-inflammatory medications, physical therapy orthe right kind of exercise. But for others, onlysurgical intervention will help.

Thanks to recent medical advances,patients with ongoing hip pain who don’trequire a hip replacement may now be treatedwith minimally invasive surgery. The procedure,called hip arthroscopy, allows surgeons to

diagnose and repair most injuries through tinyincisions in the hip instead of larger incisionslike those needed for replacements. This lessinvasive approach usually means less pain and aquicker recovery for the patient.

While a hip replacement may be needed ifthere is severe hip trauma or damage fromarthritis in the joint, hip arthroscopy is mostoften used to treat a specific and less severecondition that may be causing pain. This makesit beneficial for younger, more active people.

Historically, active individuals in the 30–50 age range with chronic hip pain were more orless told to live through their pain until theyreached an age when a hip replacement wasfeasible. Physicians used this approach because

By Benjamin H. Huffard, MD

Medical Advances Provide New Option for Hip PainExplaining Hip Arthroscopy

Hip arthroscopy uses specialized instruments insertedthrough small incisions to remove or repair damaged tissue.

The OA Update 19

a practical treatment option simply wasn’tavailable. In some cases, doctors couldn’t evendetermine the cause of a patient’s pain becausethe injury wasn’t detectable on an x-ray.

As diagnostic techniques and instrumentsfor the hip have improved, more and moredoctors are now using hip arthroscopy todiagnose and treat injuries such as labral tears,the most common problem in the hip joint.The labrum is the ring of cartilage thatsurrounds the rim of the hip socket, alsoknown as the acetabulum, and acts as acushion. Labral tears can occur as the result ofan accident, through overuse or sometimesthrough basic wear and tear.

In addition to labral tears, two otherinjuries commonly treated with arthroscopicprocedures are hip impingement, a condition inwhich a lack of room between the head of thefemur, or the ball, and the acetabulum, orsocket, causes painful friction when the hip isflexed and the removal of loose bodies in thejoint—small pieces of soft tissue or bone thatare usually the result of trauma such as a fall,accident or sports injury.

Similar to knee and shoulder arthroscopy,which have been performed for many years,hip arthroscopy includes the use of a narrowscope and specialized instruments. The scopeis attached to a camera and is inserted into thejoint through a small incision, allowing thesurgeon to see the injury and the areasurrounding it. The hand instruments areinserted through another incision and are usedto remove or repair the damaged tissue.Because the whole procedure is performedthrough keyhole-size incisions, the patient canusually return home that same day. In manycases, hip arthroscopy allows for a quickreturn to activity, with the least amount ofpain possible, while also diminishing the riskof arthritis and possibly even delaying theneed for a hip replacement.

Dr. Huffard spent a year as a sports medicinefellow at the Steadman Hawkins Clinic in Vail,Colo., training with Dr. Marc Philippon on min-imally invasive and arthroscopic treatment of softtissue injuries around the hip. Dr. Huffardspecializes in arthroscopic surgery of the shoulder,knee and hip.

20 The OA Update

No athlete should return to sport or other at-risk participation when symptoms of aconcussion are present and recovery isongoing. The best way to prevent difficultieswith a concussion is to manage the injuryproperly when it does occur. Here are somecommonly asked questions and answersregarding concussion injuries:

What is a concussion?A concussion is any temporary change in howthe brain works caused by injury to the headthat may or may not involve a loss ofconsciousness. This can be a direct blow tothe head or a hit to the body causing shakingof the head. Another term for concussion ismild traumatic brain injury (MTBI). Asports-related concussion is specific to aninjury while playing sports and willtemporarily limit involvement with sports.

Is sports-related concussion common?Yes, sports-related concussion is commonespecially in collision sports like ice hockey,boxing and football, but a sports-relatedconcussion can occur in any sport. Estimatesare that 5 percent of injuries in high schoolsports are concussions, with a higher rate incertain sports (60 percent in football).

Unfortunately, many more concussions gounrecognized and untreated.

How do I know if I have a concussion?Symptoms of a concussion can be very subtle(irritability, ringing in the ears, nausea,difficulty concentrating, difficulty sleeping,personality changes, sensitivity to lights orsounds or just not feeling right). Symptomscan also be more obvious (headache, confusion,loss of memory, clumsiness, change in vision,appearing dazed). ANY change to normalbrain function is a concussion no matter howminor the symptom may be or how long thesymptoms last. Even a “ding” or getting your“bell rung” is a concussion.

What do I do if I have a concussion?Tell your athletic trainer or team physician. Theonly treatment for sports-related concussion isrest. This will involve stopping all sportparticipation until all symptoms have resolvedand to return with a slow increase in activitywithout symptoms recurring. Sometimes restneeds to include limiting school or workactivity. If the symptoms are prolonged (morethan seven days), your doctor may be able tohelp the symptoms with some medications;typically, no medications are needed.

Will my brain return to normal?With a single concussion and appropriate rest,typically you will regain all your normal brainfunction within 7–10 days. Sometimes aneuropsychological test (ImPACT) will be usedto help determine when normal brain functionhas returned. We cannot determine how severea concussion is until all the symptoms havegone away, and we have no way to predict whenthey will resolve. We do not know how manyconcussions one person can have in a lifetimebefore permanent brain injury occurs. Thisnumber is different for each person. We onlyknow if the damage is permanent when thesymptoms don’t go away.

Can I prevent a concussion?The only way to prevent a concussion is to avoidinjury to your head. No equipment (helmet,mouthguard) has been proven to decrease therate or severity of concussion, but they doprevent other injuries (cuts, tooth damage, eyeinjury, etc) and should be worn.

Dr. Ouellette serves as team physician for BowdoinCollege and Old Orchard Beach High School. He as-sists with coverage for the Portland Pirates (AHL) andthe U.S. National Soccer Teams. He utilizes the Im-Pact test on his athletes to ensure a safe return to sports.

Understanding Sports-Related ConcussionsUnderstanding Sports-Related ConcussionsBy Lucien R. Ouellette, MD

The OA Update 21

OA Centers for Orthopaedics thanks the following advertisers for making this publication possible.

Berry, Dunn, McNeil & Parker ..................................page 9

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Ethos Marketing and Design ...............................page 23

Genzyme Corporation .................................. page 11 & 12

Hebert Construction, LLC ....................................... page 7

Ledgewood Construction ..................................... page 22

Maine Heart Surgical Associates ......................... page 17

Maine Medical Center ...........................................page 19

Marzilli’s Embroidery Plus 6 Marzilli Way Windham, ME 04062 (207) 893-2948 • (207) 893-0558 Faxmarzillinc@adelphia.net

Mercy Hospital ....................................................... page 2

New England Medical Transcription, Inc. ............ page 21

New England Rehabilitation

Hospital of Portland ............................................ page 22

Outdoor Service Company, Inc. 219 Roosevelt Trl. Windham, ME 04062(207) 892-7700

PDT Architects.......................................................page 21

Pratt-Abbott Inc. ................................................. page 21

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Spectrum Medical Group ................................. back cover

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22 The OA Update

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