ACL Reconstruction 2009 FL.pdfan injury to the medial collateral ligament, or inside knee ligament,...

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JournalThe official publication of the Jacksonville Orthopaedic Institute Volume VII Issue II

www.JOIonline.net

ACL Reconstruction 2009Surgery & Graft Selection

Arthrosurface

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Greetings from thePresident of JOI...Journal

Fall/Winter 2009

JACKSONVILLE ORTHOPAEDIC INSTITUTE1325 San Marco Boulevard, Suite 701

Jacksonville, FL 32207(904) 858.7199

Patrick A. HintonExecutive Director

The mission of the Jacksonville Orthopaedic Institute (JOI) is to provide high qualityorthopaedic health care for our patients

with musculoskeletal disorders.

The “official sports medicine partner”of the Jacksonville Jaguars

JOI providesexpertise in:

• HAND

• FOOT & ANKLE

• JOINT REPLACEMENT

• SPINE

• SPORTS MEDICINE

We are dedicated to fostering apersonalized and compassionate

level of medical care for our patients.

The JOI Journal is designed & published by Custom Publishing Design Group.

www.mycompanymagazine.com

To advertise in an upcoming issue pleasecontact Rebecca Reed at 800.246.1637.

Jacksonville Orthopaedic Institute continues to celebrate its 15th year of service through the expansion of our physician members to meet the

needs of the growing greater Jacksonville communities. We are pleased to welcome two new doctors to our group practice, which now totals 32 serving at seven convenient locations around Northeast Florida:

Dr. Bates graduated Cum Laude from Towson State University (Towson, MD) with a Bachelor of Science, majoring in biology and minoring in mathematics. He attended the University of Maryland School of Medicine (Baltimore, MD) where he

graduated as a Doctor of Medicine. Dr. Bates completed his internship in General Surgery at the National Naval Medical Center (Bethesda, MD), followed by service as a Naval Flight Surgeon. He then completed an Orthopaedic Surgery Residency at the University of Florida (UF & Shands, Jacksonville, FL). He received the Marshall S. Horwitz Resident of the Year Award, the Society of Teaching Scholars Outstanding Resident Teacher Award, and was awarded first place for the Resident Research Award and Orthobowl Residency Challenge of the Florida Orthopaedic Society. Dr. Bates was later inducted into the Towson University Hall of Fame, and has completed a fellowship in Orthopaedic Sports Medicine at the Baylor College of Medicine.

While in Jacksonville, he has been team physician for a variety of high schools (Parker, Forrest, Paxon), and has volunteered with the Jacksonville Sports Medicine Program. He and his wife, Leigh, have three children and reside in Fleming Island.

Dr. Kaplan graduated from Tulane University (New Orleans, LA) with a Bachelor of Science, majoring in cell and molecular biology and was distinguished as Summa Cum Laude with Honors, Phi Beta Kappa, and a member of numerous National Honor Societies. He attended New York University School of Medicine (New

York, NY) where he graduated as a Doctor of Medicine and was distinguished in the Alpha Omega Alpha honor society. Dr. Kaplan completed his residency in Orthopaedic Surgery at New York University Hospital for Joint Diseases (New York, NY) where he was chosen as an Executive Chief Resident, contributed over twenty orthopaedic publications, earned research awards, and received specialized training in orthopaedic trauma surgery at Seattle’s Harborview Hospital, one of the busiest and most respected trauma centers in the country. He completed a fellowship in orthopaedic sports medicine at the world-renowned Kerlan-Jobe Orthopaedic Clinic (Los Angeles, CA). During his fellowship, he assisted the head team physician in the orthopaedic

Kevin M. Kaplan, MD

Aaron M. Bates, MD

Continued on Page 4

Michael S. Scharf, MD

4 www.JOIonline.net JOI Journal

To learn more: 904-387-3800 [email protected]

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care of the 2009 World Champion Los Angeles Lakers. In addition, he served as an assistant team physician for the Los Angeles Dodgers, Los Angeles Kings, Los Angeles Sparks, Anaheim Ducks, and Loyola Marymount University. Working among innovators in the field of sports medicine, Dr. Kaplan has been trained in cutting-edge arthroscopy of the shoulder, elbow, hip and knee, as well as in joint preserving and reconstructive procedures of the shoulder and elbow. He has presented his research at numerous national meetings and is a fellow-member of the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America.

Just as we provide our expertise in medical care, we, along with our JOI employees, join together multiple times during the year to participate in major community events. We are pleased to have a cycling JOI Team in the MS150, where we will join 2,500 cyclists for a two-day adventure along Northeast Florida’s scenic coastline (St. Augustine to Daytona Beach – and back, for some). This event is all for a good cause, the Multiple Sclerosis Society.

This Fall you will see many JOI physicians as well as Rehabilitation trainers “on the field” of many area high schools, colleges and universities. We work closely with all of our partners, including the Jacksonville Jaguars, to ensure these athletes are taken care of in case of a sports injury on the field. Our newest “sports medicine partner” is Florida State College, formerly FCCJ.

Also, we hope you will visit our revamped website, www.joionline.net – let us know what you think. We hope that it will serve as your first resource for when you are in need of orthopaedic care.

Thank you for allowing us to serve you and your family!

Michael S. Scharf, MDSpine, Joint Replacement

SAN MARCOPresident, Jacksonville Orthopaedic Institute

Congratulations to Patrick M.J. Hutton, MD

(Sports Medicine - ORANGE PARK) for his election as President of the

Florida Orthopaedic Society.

Dr. Hutton hopes to involve the Society with the Wounded Warrior Project,

headquartered in Jacksonville.

Continued from Page 3

JOI Rehabilitation CentersBEACHES 436 Jacksonville Drive Jacksonville Beach, FL 32250 Phone: 904-247-3324 Fax: 904-247-3926

MANDARIN 12276 San Jose Blvd., Suites 716 & 717 Jacksonville, FL 32233 Phone: 904-288-9604 Fax: 904-288-9643

NORTH 12961 North Main Street Suite 201-2 Jacksonville, FL 32218 Phone: 904-757-2474 Fax: 904-757-5541

POINT MEADOWS 7740 Point Meadows Drive (Gate Pkwy. and 9A), Suite 1 & 2 Jacksonville, FL 32256 Phone: 904-564-9594 Fax: 904-564-9687

RIVERSIDE/WESTSIDE 4339 Roosevelt Blvd., Suite 600 Jacksonville, FL 32210 Phone: 904-389-8570 Fax: 904-389-8599

SAN MARCO 1325 San Marco Blvd., Suite 102 Jacksonville, FL 32207 Phone: 904-858-7045 Fax: 904-858-7047

SOUTH 14985 Old St. Augustine Road Suite 106 (Durbin Crossing) Jacksonville, FL 32258 Phone: 904-288-9491 Fax: 904-288-9698

UNIVERSITY 5737 Barnhill Drive, Suite 204 Jacksonville, FL 32207 Phone: 904-733-9948 Fax: 904-733-9984

The Doctors and Staff at Jacksonville Orthopaedic Institute wish to thank the following businesses for their support:

Akerman Senterfitt

Baptist Health

Baptist Pharmacy

Bennett’s Business

Boger’s Shoes

Durden Surgical

PSS

Stryker

GE Healthcare

Jacksonville Orthopaedic Institute www.JOIonline.net 5

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For Getting Better, It Doesn’t Get Any Better!When on the road to recovery, every stop on your journey is important. That’s why JOI offers its own first-rate rehabilitation facilities. We find it is the best way to offer cohesive, streamlined care. As with every aspect of your care, JOI will provide expert therapists, the best equipment and technology, and an outstanding environment to bring about the best results. All you need is the desire to improve. We will encourage you along the way to keep you motivated and thinking positive about your treatment. If for a particular reason you choose a non-JOI rehabilitation facility, we can work with other rehabilitation facilities as well. n

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nterior cruciate ligament (ACL) tears are one

of the most common serious sports injuries. It

is estimated that 200,000 ACL injuries occur in

the United States each year and more than 100,000 ACL

reconstructive surgeries are performed annually. The ACL

plays a vital role in maintaining knee stability and an ACL

deficient knee can result in recurrent instability, meniscus

tears and articular cartilage degeneration. Many procedures

were done for ACL tears in the past, but beginning in the late

1980’s, arthroscopic ACL reconstruction surgery, initially

using a central third of the patella tendon, has proved the

most successful and has been refined and improved over the

past 20 years.

These injuries commonly occur during deceleration,

cutting, or twisting maneuvers (Figure 1). Patients will often

report sensing a pop within the knee and then subsequently

swelling, or “water on the knee”, with a sensation of

instability when they are walking. When associated with

an injury to the medial collateral ligament, or inside knee

ligament, these injuries are much more painful and appear

much more serious. However, patients with isolated ACL

injuries may improve over a week or two and the athlete

does not recognize the seriousness of the injury until they

try to return to sport and experience a buckling or instability

sensation in their knee. The diagnosis of an ACL tear is

made by a thorough physical examination of the knee, often

including X-rays and an MRI. A tear of the ACL has become

the most feared injury in sports. These surgical procedures,

by R. Stephen Lucie, MD Sports Medicine, Joint ReplacementSan Marco

ACL Reconstruction 2009Surgery & Graft Selection

AR. Stephen Lucie, MD

1. ACL injuries commonly occur during deceleration, cutting, or twisting maneuvers


described above, have allowed most

athletes to return to their respective

sports, although usually not before 6 to

12 months of vigorous rehabilitation.

Not all patients with an ACL tear

require surgical reconstruction,

however, most younger and active

patients will require this for the knee

to achieve the stability to return to full

activity. Physiological age is probably

more important than chronological

age, and recreational activities

and activity level will ultimately

dictate whether surgery is necessary.

Sometimes the MRI will show

associated injuries such as ligamentous

injury, meniscal injuries or cartilage

damage which would require, at the

least, arthroscopic treatment.

Once the diagnosis of an ACL tear

is made there often will be a delay as

the knee quiets down from an acute

injury, and it is not uncommon for the

physician to wait three to six weeks

prior to ACL reconstruction. This

delay will help prevent stiffness and

may improve rehabilitation.

Once the surgeon and the patient

have decided that ACL reconstruction

will be required, the first important

decision the doctor and the patient

make is on the type of graft for the ACL

reconstruction. In the younger and more

athletic patient population a central

third patella tendon autograft is often

the graft of choice (Figure 2). This

graft is chosen because of its strength,

characteristics, rigid fixation, bone-

to-bone healing and favorable clinical

outcome. This does, however, make the

largest scar of the graft choices, often is

somewhat more painful than other types

of reconstruction and may result in

some anterior knee pain and pain while

kneeling. The use of autograft tissue

has been shown to have faster healing,

greater graft strength at 6 to 12 months

and a lower failure rate.

Another excellent graft choice is

the hamstring tendons located on the

inside and just above the knee in the

posterior aspect of the knee (Figure

3). In this surgery the gracillis and

semitendinosus, which are two of the

most easily available hamstrings, are

harvested through a small incision just

below the knee. These two tendons

are then quadrupled and fixed in bone

tunnels with a variety of different

fixation devices. The hamstring

autografts have an advantage of

decreased donor site pain and

problems, preservation of the extensor

mechanism of the knee, excellent graft

strength and are the preferred choice in

young patients who are still growing.

The disadvantage of the hamstring

is that without bone plugs they have

slightly less secure initial fixation and

some studies have shown increased

laxity especially in females and mild

hamstring weakness. In many parts of

the country these are the procedures of

choice for all athletes, however, they

seem to be ideal in patients whose

sports require frequent kneeling such

as wrestlers and middle aged athletes

who would like autograft tissue, but

do not want to go through the pain and

rehabilitation of a bone-patella tendon

graft.

Allograft, or cadaver, grafts are

often chosen for those patients who

are older and those who are concerned

with cosmesis and want the smallest

scar and the easiest rehabilitation.

There have been safety concerns

regarding the use of allograft and

nationally the infection rate has been

higher than that of using one’s own

tissue and there is a very small chance,

1:1,000,000, of contracting AIDS

or hepatitis from this type of tissue.

When choosing an allograft tissue for

an ACL reconstruction we definitely

recommend using an accredited tissue

bank (ATB) and at JOI we are very

particular as to the source of our

allografts and we have an exclusive

relationship with the Musculoskeletal

Transplant Foundation who have

reported no associated infections with

almost two million units transplanted.

Although allograft surgery represents

a smaller procedure to the patient,

more recent reports have indicated

that these grafts do not have the same

strength between six months and a

year as autograft tissue and have a

somewhat higher failure rate in active

individuals.

Today’s ACL patients are very

savvy. They often do their own

2. Bone tendon bone ACL

3. Hamstring ACL Graft

internet research and many make graft decisions depending

on how their teammates or friends did with a particular

type of procedure. There is no right or wrong answer to

graft selection, however, in my practice BTB autografts are

generally selected in younger and more active patients and

season-to-season athletes. Hamstring grafts can also work

for these same patients as well as providing a somewhat

easier rehabilitation to middle age and female patients with

slightly lower demands. Allograft tissue is usually chosen

by older patients, those with back to work concerns and

wish an easier rehabilitation, and females with cosmetic

concerns.

There has been some recent interest in Double Bundle

ACL reconstruction. This type of surgery requires two

separate grafts with four separate drill holes in the knee.

While this concept more accurately replaces the true

anatomy of the ACL and may control rotatory instability

better, it is technically more demanding, requires increased

surgical time and thus far has not demonstrated clinical

superiority in comparison studies with accurately placed

and well performed single bundle reconstructions.

While the surgery is certainly an important aspect in

a successful result from ACL surgery, the rehabilitation

is equally important. Today’s rehabilitation is more

aggressive than earlier programs and often allows the

patient to fully weight bear immediately after surgery

with crutches being discontinued after 10 to 14 days.

Full range of motion is emphasized early and a complex

progressive rehabilitation program requires three to six

months, often allowing the patients to run at four months,

and a return to the sport when quadriceps strength is 85

to 90% that of the uninjured leg. The average time to full

recovery and return to sport, is between six months and a

year, depending on the athlete’s progress. Often there are

some issues during the first year of participation following

this surgery, and improvement continues for over two

years. High performance athletes may not return to their

pre-injury status, but most recreational athletes can return

to their sport at some level. Associated injuries such as

cartilage damage or meniscus tears often affect the clinical

results, and may result in arthritis in years to come. The

good news for most, is that while tearing your ACL is

never a good idea, the chances to return to play are greater

now than ever before.

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Touching Lives Experience, Expertise & Excellence

Brandon J. Kambach, MDSpine

Baptist South & San Marco

Gregory C. Keller, MD Spine, Sports Medicine,

Joint ReplacementSan Marco

Garry S. Kitay, MDHand, Joint Replacement,

Sports MedicineSan Marco

Robert J. Kleinhans, MD Hand, Joint Replacement,

Sports Medicine University

Steven J. Lancaster, MD Sports Medicine,

Joint Replacement, HandBeaches & Point Meadows

R. Stephen Lucie, MDSports Medicine,


Stanton L. Longenecker, MDJoint Replacement,

Sports MedicineRiverside

Jennifer L.M. Manuel, MDHand


H. Lynn Norman, MDSports Medicine,

Joint Replacement Riverside

Richard A. Picerno II, MD Sports Medicine,

Joint ReplacementBaptist South

Gregory Solis, MDFoot & Ankle,

Sports MedicineBaptist South

Maxwell W. Steel III, MD Sports Medicine, Foot & Ankle,

Joint Replacement University

William G. Pujadas, MDJoint Replacement, Spine,


Robert G. Savarese, DOSpine


Michael S. Scharf, MDSpine,


Bruce Steinberg, MD Hand, Joint Replacement,

Sports MedicineBaptist South & San Marco

Carlos R. Tandron, MD Sports Medicine,

Joint Replacement San Marco

M. John von Thron, MD Sports Medicine,

Joint Replacement, Foot & Ankle Beaches

Dale A. Whitaker, MDSports Medicine,


Edward D. Young, MD Sports Medicine,


William N. Campbell, MDSports Medicine,

Joint Replacement, Foot & Ankle

Riverside

Stephen J. Augustine, DOSports Medicine,

Joint ReplacementOrange Park & Riverside

Hiram A. Carrasquillo, MD Foot & Ankle,


Steven M. Crenshaw, MD Sports Medicine,


David A. Doward, MDSpine, Sports Medicine

San Marco

bones and joints.

Jacksonville Orthopaedic Institute (JOI) offers 30 specialty–trained physicians, many with fellowships, who are dedicated to delivering comprehensive care for the muscles,

Our diverse practice includes five Centers of Expertise:��

Of ficial Spor tsMedicine Par tner

Rehabilitation CentersBeaches 904.247.3324 North 904.757.2474Point Meadows 904.564.9594Riverside/Westside 904.389.8570San Marco 904.858.7045South 904.288.9491University 904.733.9948

MRI CentersBeaches � Riverside/Westside��San Marco

Office LocationsBaptist South 904.880.1260Beaches 904.241.1204Orange Park 904.276.5776Point Meadows 904.241.1204Riverside 904.388.1400San Marco 904.346.3465University 904.739.3319

1st Call JOI!Questions about our physicians,

facilities or treatment options?

Timothy R. Hastings, MDSports Medicine,

Foot & AnkleBeaches & Point Meadows

Patrick M.J. Hutton, MD Sports Medicine

Orange Park

Sunday U. Ero, MD Spine

Riverside

Richard R. Grimsley, MD Joint Replacement,

Sports MedicineOrange Park & Riverside

Philip R. Hardy, MD Sports Medicine,


Touching Lives Experience, Expertise & Excellence

Brandon J. Kambach, MDSpine


Gregory C. Keller, MD Spine, Sports Medicine,


Garry S. Kitay, MDHand, Joint Replacement,


Robert J. Kleinhans, MD Hand, Joint Replacement,

Sports Medicine University

Steven J. Lancaster, MD Sports Medicine,


R. Stephen Lucie, MDSports Medicine,


Stanton L. Longenecker, MDJoint Replacement,

Sports MedicineRiverside

Jennifer L.M. Manuel, MDHand


H. Lynn Norman, MDSports Medicine,

Joint Replacement Riverside

Richard A. Picerno II, MD Sports Medicine,

Joint ReplacementBaptist South

Gregory Solis, MDFoot & Ankle,

Sports MedicineBaptist South

Maxwell W. Steel III, MD Sports Medicine, Foot & Ankle,

Joint Replacement University

William G. Pujadas, MDJoint Replacement, Spine,


Robert G. Savarese, DOSpine


Michael S. Scharf, MDSpine,


Bruce Steinberg, MD Hand, Joint Replacement,

Sports MedicineBaptist South & San Marco

Carlos R. Tandron, MD Sports Medicine,

Joint Replacement San Marco

M. John von Thron, MD Sports Medicine,

Joint Replacement, Foot & Ankle Beaches

Dale A. Whitaker, MDSports Medicine,


Edward D. Young, MD Sports Medicine,


William N. Campbell, MDSports Medicine,

Joint Replacement, Foot & Ankle

Riverside

Stephen J. Augustine, DOSports Medicine,

Joint ReplacementOrange Park & Riverside

Hiram A. Carrasquillo, MD Foot & Ankle,


Steven M. Crenshaw, MD Sports Medicine,


David A. Doward, MDSpine, Sports Medicine

San Marco

bones and joints.

Jacksonville Orthopaedic Institute (JOI) offers 30 specialty–trained physicians, many with fellowships, who are dedicated to delivering comprehensive care for the muscles,

Our diverse practice includes five Centers of Expertise:��

Of ficial Spor tsMedicine Par tner

Rehabilitation CentersBeaches 904.247.3324 North 904.757.2474Point Meadows 904.564.9594Riverside/Westside 904.389.8570San Marco 904.858.7045South 904.288.9491University 904.733.9948

MRI CentersBeaches � Riverside/Westside��San Marco

Office LocationsBaptist South 904.880.1260Beaches 904.241.1204Orange Park 904.276.5776Point Meadows 904.241.1204Riverside 904.388.1400San Marco 904.346.3465University 904.739.3319

1st Call JOI!Questions about our physicians,

facilities or treatment options?

Timothy R. Hastings, MDSports Medicine,

Foot & AnkleBeaches & Point Meadows

Patrick M.J. Hutton, MD Sports Medicine

Orange Park

Sunday U. Ero, MD Spine

Riverside

Richard R. Grimsley, MD Joint Replacement,

Sports MedicineOrange Park & Riverside

Philip R. Hardy, MD Sports Medicine,


Jacksonville Orthopedic Institute (JOI) offers 32 specialty-trained physicians,many with fellowships, who are dedicated to delivering comprehensive care for the muscles, bones and joints.

Our diverse practice includes fi ve Centers of Expertise: • Foot & Ankle • Hand • Joint Replacement • Spine • Sports Medicine

Our mission is to provide the highest level of coordinated care so all aspects ofrecovery are seemlessly integrated from initial diagnosis through rehabilitation.

Serving this region, we have seven convenient offi ce locations, eight rehabilitationcenters and three MRI centers.

JOI accepts more than 140 health plans, including Aetna, Blue Cross Blue Shieldof Florida, CIGNA, Medicare, Humana, United and workers’ compensation. Wemake every effort to work with our referring Primary Care physicians to serve theneeds of patients and their plan requirements.

Questions about our physicians, facilities or treatment options?

Web-based education available at www.joionline.net/education

Stephen J. Augustine, DOSports Medicine;Joint ReplacementRiverside

Aaron Michael Bates, MDSports MedicineOrange Park

William N. Campbell, MDSports Medicine;Joint Replacement; Foot & AnkleRiverside

Hiram A. Carrasquillo, MDFoot & Ankle; Sports MedicineSan Marco

Steven M. Crenshaw, MDSports Medicine;Joint ReplacementSan Marco

David A. Doward, MDSpine; Sports MedicineSan Marco

Sunday U. Ero, MDSpineRiverside

Richard R. Grimsley, MDJoint ReplacementOrange Park & Riverside

Philip R. Hardy, MDSports Medicine;Joint ReplacementSan Marco

Timothy R. Hastings, MDSports Medicine;Foot & AnkleBeaches & Point Meadows

Patrick M.J. Hutton, MDSports MedicineOrange Park

Brandon J. Kambach, MDSpineBaptist South

Kevin Michael Kaplan, MDSports Medicine;Joint ReplacementSan Marco

Gregory C. Keller, MDSpine; Sports Medicine;Joint ReplacementSan Marco

Garry S. Kitay, MDHand; Joint Replacement;Sports MedicineSan Marco

Robert J. Kleinhans, MDHand; Joint Replacement;Sports MedicineUniversity

Steven J. Lancaster, MDSports Medicine;Joint Replacement; HandBeaches & Point Meadows

Stanton L. Longenecker, MDJoint Replacement;Sports MedicineRiverside

R. Stephen Lucie, MDSports Medicine;Joint ReplacementSan Marco

Jennifer L.M. Manuel, MDHandBaptist South & San Marco

H. Lynn Norman, MDSports Medicine;Joint ReplacementRiverside

Richard A. Picerno II, MDSports Medicine;Joint ReplacementBaptist South

William G. Pujadas, MDJoint Replacement; Spine;Sports MedicineSan Marco

Robert G. Savarese, DOSpineBaptist South & San Marco

Michael S. Scharf, MDSpine; Joint ReplacementSan Marco

Gregory Solis, MDFoot & Ankle; Sports MedicineBaptist South

Maxwell W. Steel III, MDSports Medicine; Foot & Ankle;Joint ReplacementUniversity

Bruce Steinberg, MDHand; Joint Replacement;Sports MedicineBaptist South & San Marco

Carlos R. Tandron, MDSports Medicine; Joint ReplacementSan Marco

M. John von Thron, MDSports Medicine;Joint Replacement; Foot & AnkleBeaches

Dale A. Whitaker, MDSports Medicine;Joint Replacement; HandBeaches & Point Meadows

Edward D. Young, MDSports Medicine;Joint Replacement; HandBeaches & Point Meadows

Baptist South14546 Old St. Augustine Road, Suite 107 - Jacksonville, FL 32258P: 904.880.1260 • F: 904.880.1210

Beaches410 Jacksonville Drive - Jacksonville Beach, FL 32250P: 904.241.1204 • F: 904.241.7331

Orange Park454 Blanding Boulevard - Orange Park, FL 32073P: 904.276.5776 • F: 904.276.5958

Point Meadows7740 Point Meadows Drive, Suite 7 - Jacksonville, FL 32256P: 904.241.1204 • F: 904.241.7331

Riverside2 Shircliff Way, DePaul Building, Suite 300 - Jacksonville, FL 32204P: 904.388.1400 • F: 904.388.9644

San Marco1325 San Marco Boulevard, Suite 200 - Jacksonville, FL 32207P: 904.346.3465 • F: 904.396.0388

University5737 Barnhill Drive, Suite 102 - Jacksonville, FL 32207P: 904.739.3319 • F: 904.448.1416

Beaches 436 Jacksonville Drive - Jacksonville Beach, FL 32250 • P: 904.247.3324 • F: 247.3926

Mandarin 12276 San Jose Blvd., Suite 716 & 717 - Jacksonville, FL 32223 • P : 904.288.9604 • F: 288.9643

North 12961 North Main Street, Suite 201 & 202 - Jacksonville, FL 32218 • P: 904.757.2474 • F: 757.5541

Point Meadows 7740 Point Meadows Drive, Suite 1 & 2 - Jacksonville, FL 32256 • P: 904.564.9594 • F: 564.9687

Riverside/Westside 4339 Roosevelt Blvd., Suite 600 - Jacksonville, FL 32210 • P: 904.389.8570 • F: 389.8599

San Marco 1325 San Marco Blvd., Suite 102 - Jacksonville, FL 32207 • P: 904.858.7045 • F: 858.7047

South 14985 Old St. Augustine Road, Suite 106 - Jacksonville, FL 32258 • P: 904.288.9491 • F: 288.9698

University 5737 Barnhill Drive, Suite 204 - Jacksonville, FL 32207 • P: 904.733.9948 • F: 733.9984

JOI patients cango home with

their prescriptions.

• Conveniently located

• Full range of prescriptionand over-the-countermedications

• Most insurance plansaccepted

Baptist Pharmacy PavilionBaptist Medical Center Downtown Pavilion Medical Building, 836 Prudential Drive904.202.5288

Baptist Pharmacy BeachesBaptist Medical Center Beaches1370 13th Avenue South, Jacksonville Beach904.241.0116

Baptist Pharmacy NassauBaptist Medical Center Nassau1250 South 18th Street, Fernandina Beach904.261.3251

Baptist Pharmacy SouthBaptist Medical Center SouthMedical Office Building, 14546 Old St. Augustine Road904.821.6690

Baptist Pharmacy Children’sNemours Children’s Clinic, 807 Children’s Way904.390.3601

Baptist Pharmacy San MarcoReid Medical Building, 1325 San Marco Boulevard904.202.5292

Baptist Pharmacy Lane AvenueBaptist Primary Care, 810 Lane Avenue South904.693.2389

The Human Spine

Since our founding in 1939, Stryker has worked side-by-side with surgeons in the operating room. As medicine has evolved, so have we.

Now, everywhere you look, Stryker Spine is helping people lead active, more comfortable lives. Thanks to our relentless pursuit to design and develop implants for procedural innovations, we can provide neurosurgeon and orthopedic surgeon customers with the tools they need to help their patients.

Stryker has been setting standards within the healthcare industry for years. Stryker Spine continues in that tradition by joining together with surgeons to create new perspectives on spinal health.

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very year new products emerge that are designed to catch the eyes of the public and the orthopaedic

surgeons who serve the public. Some orthopaedic implants are introduced to provide one implant to take care of a broad spectrum of arthritis. An example would be a total knee replacement. Other orthopaedic implants are introduced to provide treatment of a very narrow spectrum of arthritis. The Arthrosurface “Unicap” is an example of a narrow spectrum implant.

In medical terms, the Unicap was developed to care for a small percentage of patients with arthritis of the knee who have very specific indications for its use.

In order to gain a better understanding of the indications, the author proposes the following analogy.

Consider the asphalt street you drive every day as a model for arthritis in a knee. Asphalt is the surface covering of the road as articular cartilage is the surface covering the ends of the bones. As the street is used over many years, there will be gradual wear which, if left untended, will lead to small cracks in the road surface. Small grains of the asphalt surface will break free and be found along the roadside. In the knee, the same small particles, called wear debris, occur and are cleaned up by special cells and fluids within the knee. Sometimes, areas of weakness or damage to the road will lead to potholes in the road surface. These potholes (Figure 1-2) can cause quite a jolt to your car when it rides over them and will lead to your call to the city to have the pothole repaired. If only you could call your orthopaedist to repair the same potholes in your knee!

In younger patients, articular cartilage potholes occur and can be repaired with Autologous Cartilage Implantation, a process that requires a major surgery and long recovery. Another technology, Osteoarticular Allografts, OATS, uses plugs of cartilage to be removed from one area of the knee and implanted into the pothole, alas robbing Peter to pay Paul. Yet another treatment attempts to stimulate cartilage development using a technique called Microfracture which, while popular, has not had the support of the medical literature.

Middle age patients have been treated with osteotomies which transfer weight from one side of the knee to the healthier other side. Still others undergo either partial or total resurfacing, the partial or total knee replacement.

Now a novel new treatment of articular cartilage defects has been introduced. The Arthrosurface Unicap was developed to fill articular surface defects or potholes with a metal surface which is less than half the thickness of a partial or total knee replacement. It can be used to fill the pothole of a patient who is not a good candidate for Autologous Cartilage Implantation (ACI), or has a defect too large for the OATS procedure.

Working through smaller, truly minimally invasive incisions, surgeons can now fill in the gaps left by the wear and tear defects like the potholes in the street.

Arthrosurface

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by Stanton L. Longenecker, MD Surgery of the Knee, Sports Medicine riverSide

Stanton L. Longenecker, MD

2. Pothole Filled1. Pothole in Femur


Because of the smaller incisions, most patients recover from their surgery with much less effort (physical therapy).

The procedure is new and, as such, how long it will provide sustained relief is as yet not known. Most of the implants are still providing excellent relief at three years. Fortunately, for those implants that do not provide the patient with the outcome they were hoping for, the conversion to partial or total knee is straightforward and does not lead to a more difficult surgery.

When a younger patient is faced with the decision to undergo a major procedure to provide relief when an arthroscopic procedure on their articular cartilage fails, the Arthrosurface Unicap /Hemicap may well be the bone sparing, less invasive procedure they were seeking.

“Asphalt is the surface covering of the road as articular cartilage is the surface covering the ends of the bones.”

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Older Americans are more apt to have severe nutritional deficiencies than younger

people, increasing their risks of seri-ous health problems as a result.

One in four elderly patients suf-fers from malnutrition, according to a national survey of geriatric doctors, nurses, hospital administrators, nurs-ing homes and home care agencies. Half of all older hospital patients and two of five nursing home patients are malnourished, the survey found.

Why do so many senior citizens have nutritional deficiencies?

Diseases such as cancer, heart or lung problems diminish appetites in older patients, causing weight loss that may weaken the body’s ability to combat illness or infection.

Physical problems pose other chal-lenges. One in five older Americans have trouble walking, shopping, buy-ing or cooking food. Dental pain or missing teeth can also make eating difficult.

Economic problems also contrib-ute to poor nutrition. Up to 40% of older Americans have incomes less than $6,000 a year, making it difficult to buy enough foods needed to stay healthy.

Some prescription medications com-monly taken by the elderly can cause loss of appetite, nausea, digestive problems, or confusion. Seniors often skip meals; those with Alzheimer’s may simply forget to eat.

Living alone has been linked to poor eating habits among the elderly. Taste sensations diminish with age, which By Miriam Raftery

Seniors Have Special Nutrition Needs


may reduce interest in foods. Depression and alcoholism also lessen appetites.

Not all deficiencies are obvious. Lack of cal-cium and Vitamin D can lead to osteoporosis, which is often not detected until a bone fracture occurs. Another common deficiency in the elderly is Vitamin B-12, since absorption dimin-ishes with age.

Recently, senior nutrition guidelines have been established by The Nutrition Screening Initiative (NSI), a coalition of groups including The American Dietetic Association, The National Council on the Aging, Inc., and The American Academy of Family Physicians. NSI advises physicians to provide nutritional screening and offers nutrition recommendations for specific diseases.

Nutrition therapy has been found to help alle-viate diseases common among the elderly. It is also cost-effective. The American Dietetic Association has shown that for every dollar spent on nutrition screening and intervention, at least $3.25 is saved.

Some insurance companies now cover nutri-tional therapy. Medicare pays for medical nutrition therapy for diabetes and renal disease, and may soon cover cardiovascular and other diseases.

If you’re a senior citizen, or if you’re caring for an older relative, how can you assure that nutritional needs are met?

Report sudden weight loss or gain: Any rapid change in weight may signal onset of a disease such as cancer, diabetes, or Alzheimer’s.

85% of chronic diseases in the elderly can improve with nutritional changes.


Get tested: Your doctor can assess your body mass index and check cholesterol levels, serum albumin, or other factors that may indicate if nutritional changes are needed.

Make disease-specific dietary changes: Fortunately, 85% of chronic diseases in the elderly can improve with nutritional changes, according to a report by the U.S. Senate Committee on Education and Labor.

For example, cancer patients may need added calo-ries, proteins and fluids to counter weight loss during chemotherapy. Patients with emphysema or other lung diseases may need higher fat intake to decrease carbon dioxide production and more fluids to keep pulmonary secretions thin.

Coronary heart disease patients should eat less saturated fat, more whole grains and leafy green veg-etables rich in folate. Eating three or more servings of broiled or baked fish weekly is also recommended.

(Fish oil capsules are not advised, as they may increase risk of hemorrhagic stroke in heart patients.) Those with congestive heart failure or high blood pressure should reduce salt usage, while diabetics should monitor levels of carbohydrates (starch/sugar).

Eat a well-balanced diet: For most seniors, it’s wise to eat a well-balanced diet with plenty of fruits and vegetables, whole grains, low-fat milk products, and protein sources such as lean meat, fish, or skin-less poultry. Choose foods low in saturated fats and cholesterol.

Consider supplements: If adequate nutrition can’t be achieved through diet alone, consider adding vita-min or mineral supplements. Alzheimer’s patients may need Vitamin E, for instance. Be aware that some medications or conditions may deplete the body of key nutrients. Check with your doctor before tak-ing supplements, however, since some may interfere with medications or cause other problems.

Nutrition therapy has been

found to help alleviate diseases common among the elderly. It is

also cost- effective.


Boost low weight: Patients with cancer, chronic pulmonary disease or other conditions may lose more weight than is healthy. Encourage under-weight patients to eat foods high in calories first. Choose foods high in protein to build strength. Drinking high-calorie liquid supplements, or even milk shakes, may help keep weight on when appe-tite is poor.

Help those with eating problems: Some older people have difficulty picking up utensils. Cut up portions, serve finger foods, or spoon feed if neces-sary. Try offering smaller meals but bigger snacks for those with poor appetites. For Alzheimer’s patients, eliminating distractions helps keep the focus on mealtime. Serve larger meals at breakfast and lunch, when the ability to think and function is usually best.

Ask about medications: If you notice a change in appetite or symptoms of drowsiness, weakness, diarrhea, constipation, nausea, forgetfulness or confusion, ask the doctor if medications could be at fault. Other medications may be prescribed to stimulate appetite or suppress nausea.

Limit alcohol: Your ability to metabolize alcohol changes as you grow older, intensifying alcohol’s effects. One in four older adults drinks too much alcohol, which can worsen other health problems. Limit consumption to no more than one or two alcoholic drinks per day—and don’t mix alcohol with prescription drugs.

Get help: If necessary, hire a nurse or arrange for an assisted living facility if your loved one is no longer capable of caring for himself or herself. n

For more information, contact: The Nutrition Screening Initiative 1010 Wisconsin Avenue, N.W., Suite 800 Washington, D.C. 20007 www.aafp.org/nsi/

Another helpful resource is the Caregiver Fact Sheet on Good Nutrition for Seniors, available through the National Network for Health at www.nnh.org/products/gnfs.htm.

Sports Medicine Weekend warriors and professional athletes know the physicians and staff of Jacksonville Orthopaedic Institute are on the field at area high schools, colleges and universities as well as the NFL’s Jacksonville Jaguars’ stadium. Whether it’s a broken finger or wrist injury, crushed toe or twisted ankle, shoulder dislocation or broken hip, crushed knee cap or meniscal tear, or crushed vertebrae, JOI doctors are ready!

We know you play hard whether it’s tag football or cycling down by the Suwannee. And, if your bones break and your muscles are torn, we have sports medicine orthopaedists who can help you get back on track so you can once again play – and play to win.

Our Sports Medicine Team* is dedicated to providing comprehensive care for your muscles, bones and joints. Plus, JOI has a highly trained Rehab Team dedicated to your healthy and fast recovery. Our referring physicians have come to trust

and depend on us – for you! Together, we strive to restore and sustain your health and fitness in order to reach an optimal level of activity and enhance your quality of life.

Centers of ExpertiseFoot & Ankle • Hand • Joint Replacement • Spine • Sports Medicine

32 Physicians • 7 Offices • 8 Rehab Centers

Experience, Expertise & Excellence

*JOI Sports Medicine Team: Drs. Stephen J. Augustine (Riverside), Aaron M. Bates (Orange Park), William N. Campbell (Riverside), Hiram A. Carrasquillo (San Marco), Steven M. Crenshaw (San Marco), David A. Doward (San Marco), Philip R. Hardy (San Marco), Patrick M.J. Hutton (Orange Park), Kevin M. Kaplan (San Marco), Gregory C. Keller (San Marco), Garry S. Kitay (San Marco), Robert J. Kleinhans (University), Steven J. Lancaster (Beaches, Point Meadows), Stanton L. Longenecker (Riverside), R. Stephen Lucie (San Marco), H. Lynn Norman (Riverside), Bruce Steinberg (Baptist South, San Marco), Richard A. Picerno II (Baptist South), William G. Pujadas (San Marco), Gregory Solis (Baptist South), Maxwell W. Steel III (University), Carlos R. Tandron (San Marco), M. John von Thron (Beaches), Dale A. Whitaker (Beaches, Point Meadows), Edward D. Young (Beaches, Point Meadows)

JOI Custom Publishing - Sports.indd 1 8/25/09 2:53:38 PM

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