Orthopaedics: A Tidewater Update

Volume 2 - Issue 1

ALSO INSIDE:— Unprecedented, patient-centric OrthOpaedic care

— a patient’s Story: SUrGeOn GetS BiG thUMBS Up

— SpeciaLiZatiOn: What dOeS it Mean?

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Orthopaedics: A Tidewater Update | 3

We are fortunate to live in a community with such a

wealth of medical resources. Since my arrival to Tidewater

over 15 years ago, I have witnessed a substantial increase in

medical specialization. The Sentara Heart Hospital is one of

only a few specialty heart centers in the country. The recent

addition of the Hampton University Proton Center brought

a cutting edge technology to our region and has attracted

patients nationally, as there are fewer than ten in the United

States. Last summer, our group was proud to be involved

in the opening of the Orthopaedic Hospital at Sentara

CarePlex. There are fewer than fifty exclusive orthopaedic

hospitals and we are privileged to have one in Hampton.

The undivided, dedicated delivery of orthopaedic care by a

team of professionals specializing in orthopaedics provides

unparalleled results for our patients. We discuss the new

hospital further in this edition.

The hospital specialization blends well with our practice

philosophy of providing specialist treatment to our patients.

Concentrating on a narrow focus improves outcomes and

allows the highest level of care available. I will explain further

the concept of specialization. You can see our commitment

to this goal in the articles on finger re-implantation and hip

injuries in athletes. This level of specialization is unusual

for a community our size. To further this dedication to

specialty care, we are pleased to announce the addition of

Dr. Nicholas Sablan to our group in August. He is currently

completing his orthopaedic sports medicine training at

the renowned Kerlan Jobe Clinic in Los Angeles, where he

assists in the treatment of athletes from the Lakers,

Dodgers, Angels and Kings. He will bring exciting

new technologies and treatments to our patients.

I hope you enjoy this expanded update. As always,

your comments and feedback are welcome.

Stay safe,

Loel Z. Payne, MD

We established this publication to provide the

Tidewater community with an informative

source for the latest advancements in the field

of orthopaedics. I hope we have been able to cut through

the clutter and the hype and give you a reliable source for

musculoskeletal treatments. We have received tremendous

feedback from our patients and providers and are pleased to

bring you this expanded second edition.

We lcome back for the second edition of Orthopaedics: A Tidewater Update.

4 | Orthopaedics: A Tidewater Update Volume 2 Issue 1

Our Mission:To provide the best patient experience through the highest quality of specialty orthopaedic care - blending sound medical ethics, technical excellence, integration of team members, and a commitment to leadership.

Contributing Writers:Bobbie FisherPrue Salasky

Loel Z. Payne, MD, FAAOS Colin M. Kingston, MD, FAAOSSara M. Bouraee, DPM, AACFAS

Diana Staats, RN, COHN/CM

Magazine Layout and Design: Desert Moon Graphics

Published by:

Special Thanks: J. Ryan Duffy, CEO

Orthopaedics - A Tidewater Update is an educational and informational resource for physicians and the public. Published twice per year, the magazine will introduce the physicians, their staff and facilities. In addition, it will provide updates on new achievements in orthopaedics, as well as articles on orthopaedic-related injuries and treatments.

Welcome Back for the Second Edition of Orthopaedics: A Tidewater Update

Unprecedented, Patient-Centric Orthopaedic Care

Meet the “Specialists” of Tidewater Ortho

Introducing Nick Sablan, MD

Surgeon Gets Big Thumbs up

Our Poor Ankles

Groin Pain in the Athlete: Femoral Acetabular Impingement

Specialization: What Does it Mean?

Workers’ Comp... or Not

rthopaedics: A Tidewater Update

The Specialist Group

Hampton Office901 Enterprise Parkway

Suite 900Hampton, VA 23666

Williamsburg Office5208 Monticello Avenue

Suite 180Williamsburg, VA 23188

Main Number(757) 827-2480

www. Tidewaterortho.com

3

6

1112

1518

2025

Orthopaedics – A Tidewater Update magazine is published by DocDirect Publishing, LLC, 1017 Timber Neck Mall; Chesapeake, VA 23320. Phone: 757-321-9991, fax: 757-451-6862. DocDirect Publishing, LLC specializes in creating and publishing corporate magazines for businesses.

This publication may not be reproduced in part or in whole without the express written permission of DocDirect Publishing, LLC.

Although every precaution is taken to ensure accuracy of published materials, DocDirect Publishing, LLC cannot be held responsible for opinions expressed or facts supplied by its authors.

The magazine and its publishing entities are not liable for any of information contained in any of the advertisements within the publication itself.

ContentsVolume 2 - Issue 1

13

“Since I began practicing family medicine in 1995, Virginia Health Services has been taking care of my patients in the local community. I feel confi dent referring them to any Virginia Health Services’ facilities when high quality skilled nursing care and rehabilitative services are needed.”

- Dr. Matt Halverson

Virginia Health Services.Thank You

In the care of people you know.

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When the doors opened in July of 2010 at the Orthopaedic Hospital at Sentara CarePlex , it was the realization of a vision – and exhaustive work

– more than three years in the making. As Virginia’s first dedicated orthopaedic hospital, the 55,000 square foot, 18-bed facility took orthopaedic care in the community to a new level, providing patients access to a full continuum of highly specialized inpatient orthopaedic services – from educational lectures, pre-op joint replacement classes, and surgery all the way through post-op rehabilitation and post-discharge care planning. That care is provided by the co-authors of the vision, the physicians of Tidewater Ortho.

And yet, as significant as that event was, it was only half of the vision. Working with its hospital partner, Tidewater Ortho is preparing to open the state-of-the-art CarePlex Orthopaedic Ambulatory Surgery Center in the Spring of 2011, again dedicated exclusively to the care of the orthopaedic patient.

Dr. Colin Kingston, Medical Director of the Orthopaedic Hospital at Sentara CarePlex, explains the concept: “What’s so special about this is that in a facility dedicated solely to the care of an orthopaedic patient with a musculoskeletal ailment, we’re able to pace the level of care at a much higher level. We based the concept on the Sentara Heart Hospital on the southside: when you have a dedicated hospital in the community, everybody knows it. People who have serious

cardiovascular problems go to

that hospital. That’s what we’re trying to establish here for orthopaedic patients. For our patients who require or elect to have surgery, ensuring the ultimate surgical experience is always the goal.”

Fellow surgeon Dr. Robert Campolattaro agrees: “In most surgical centers, the staff is multidisciplinary. They might be doing orthopaedic surgery on Monday, ENT on Tuesday, OB/GYN on Wednesday and so on. That center has to be able to accommodate all of those different specialties, whereas at CarePlex Orthopaedic Ambulatory Surgery Center (COASC), we have an entire center and an entire staff exclusively devoted to our orthopaedic patients. COASC reflects our practice paradigm: we’re all specialized surgeons who focus our practices exclusively in the area of our specialty.”

ImprovIng patIent CareDr. Kingston and his partners looked at the No. 1

orthopaedic hospital in the country, the Hospital for Special Surgery in New York, founded in 1863, and saw no reason they couldn’t emulate that model on a smaller scale here in this region. They began to plan.

“We went to Sentara with the idea for a dedicated ortho-paedic facility, comparing the vision to that of the (Sentara) Heart Hospital,” Dr. Kingston remembers. “We know it’ll be a good idea that

By Bobbie Fisher Unprecedented, Patient-Centric Orthopaedic Care


will be a win-win for Tidewater Ortho and Sentara– but more importantly, a win for our community, being able to provide dedicated, top notch, orthopaedic care for our patients.”

Sentara was receptive to Tidewater Ortho’s vision, “Sentara was interested in insuring that patient care was improved for orthopaedic patients in Hampton Roads,” Dr. Kingston says, pointing to recent surveys conducted from Washington DC to North Carolina that reflect an average patient satisfaction level of 65-68% – a failing grade on any scale.

In the greater Hampton Roads area, the group learned that most hospitals rated below 70%. When Dr. Kingston assumed the medical directorship of the hospital, its goal was 75%, but once again, he saw no reason not to aim higher. With its first anniversary yet to be celebrated, the hospital was recently surveyed by an independent third-party team and rated over 90%, far exceeding expectations and its own goal.

Such extraordinary success so early is no accident. “Patient-centric care is not just a hallmark of Tidewater Ortho, it’s a mandate,” says Ryan Duffy, Tidewater Ortho Administrator. He describes an intense planning period that included focus groups, which they held many times with former and current patients, encouraging them to talk candidly and listening to them share their experiences.

“We did all of this with the patient in mind,” Duffy says. “We put in the hours listening to patients give us their feedback. We wanted to find out what we needed to do to give them the ultimate surgical experience.”

These discussions weren’t held only with Sentara patients – the doctors got feedback from patients all across the region. “We wanted the input of the person who’s going to be in that bed, as well as those who will be treating and caring for that patient,” says Dr. Kingston. “When we built this facility, we involved not just patients, but also administrators, therapists, case managers, nurses – everyone in the process.”

It was an exhaustive effort, but a 90+ percent patient satisfaction rate less than a year after opening the doors makes the effort well worth it.

The effort revealed one universal truth for most any hospital experience: one bad encounter, just one bad moment during a hospital stay or surgical procedure, and the patient’s sense of the entire experience is negative. Dr. Kingston notes, “It doesn’t matter how good the surgeon is, doesn’t matter how good the facility is, and it doesn’t matter how good the outcome was – that patient’s experience is out the window. We strive to ensure that doesn’t happen at the Orthopaedic Hospital.”

The unique relationship between Sentara, the Orthopaedic Hospital at Sentara

CarePlex and the CarePlex Orthopaedic Ambulatory Surgery Center allows the

physicians to possess control over


what kind of care their patients receive – from surgeons to nurses to food service personnel to maintenance staff. Dr. Kingston emphasizes that for it to work, everyone involved needs to buy into the concept that every patient is treated like a member of the family – and “you do the best job you can for them. We believe that whoever goes into that room should go in there with a smile. When people are happy, in a friendly environment, it’s contagious, so the patient feels not only like he’s being well taken care of, but that this is a great place to come to have surgery.”

That care features a team of dedicated health care providers focused on the orthopaedic needs of each patient. Additionally, the hospital offers private rooms with a handicapped accessible bath and walk-in shower, specialized orthopaedic operating room; physical therapy and a fully-equipped rehab gym; dedicated anesthesiology services, an orthopaedic health education program and special accommodations for a family member including a sofa bed, nourishment center and two family lounge areas.

All of the Tidewater Ortho surgeons agree that the level of their involvement in this venture is rare in most environments. But they know that it is just that involvement and their willingness to help their patients succeed that distinguishes them and allows them to provide the best level of care. And they know that being able to more closely control the environment in which they work is critical, and

not just because of the level of liability they take on each time they perform surgery. It’s because they really believe that care doesn’t end when the patient leaves the OR table – that care received outside the surgical theatre affects outcomes as well. Nothing frustrates a physician more, Dr. Kingston says, than a patient who is disgruntled because of a lack of care he received – or with a complication that’s due to inappropriate care. “In the Orthopaedic Hospital, our surgeons control all aspects of care,” he notes, so that “my ability to have a positive influence on patient outcomes goes beyond the operating room. When I write an order, because I know every one of the caretakers, I know it gets done.”

With the opening of the CarePlex Orthopaedic Ambulatory Surgery Center (COASC), “It’s a really exciting time for orthopaedic care in Hampton Roads,” says Dr. Campolattaro. Many Tidewater Ortho physicians will practice in both the inpatient and outpatient facilities, although he and Dr. Nicholas Smerlis, both hand surgeons, will primarily work in the COASC, along with Dr. Sara Bouraee, a foot and ankle specialist. “For the three of us, well over 90% of our surgery – if not closer to 95% – is outpatient surgery, just by the nature of our practice.”

With Drs. Campolattaro and Smerlis, COASC boasts the only two board-certified hand surgeons on the Peninsula, who bring a degree of sophistication at the microsurgery level, which requires the use of microscopes to visualize


and repair nerves, arteries and tendons. For a community the size of the Peninsula, having just one qualified hand surgeon would be extraordinary; the ability to attract and retain two such highly skilled surgeons speaks to the unique stature of both the Orthopaedic Hospital at Sentara CarePlex and the COASC.

Computer navIgated SurgeryThe Orthopaedic Hospital at Sentara CarePlex is unique

in another way: Tidewater Ortho is the only orthopaedic group routinely utilizing computer navigation in their surgeries. In the case of a total knee replacement, Dr. Kingston says, “computer navigation allows us a level of accuracy that the human eye cannot pick up. Why is it so important? I use the example of a shipbuilder – a ship is built in pieces and sections. If each section was off by only one degree – the ship wouldn’t float. So why should a lesser degree of accuracy be acceptable in orthopaedic surgery?”

Five years ago, seeking the answer, he and Drs. Payne and Higgins set out to learn about computer navigation, and they’ve been using it ever since. “Our outcomes speak for themselves,” he says. “A better aligned knee should last longer. The number one problem with knee replacements is knee cap tracking. With computer navigated surgery, the kneecap tracks perfectly, because we can get it in perfectly – or near perfect.”

The Tidewater Ortho surgeons think other practices will follow their lead in the use of computer navigation, but a potential obstacle will be the learning curve. For the surgeon, the first several cases will take longer because the computer provides so much information that it can be overwhelming – “but the good news is that before we actually cut the bone or the cartilage, the computer tells us exactly what doing it a certain way will do to the motion of that knee. We never have to settle for ‘not perfect but acceptable.’ Before we cut, we know exactly what it’s going to do to the motion for that patient’s pathoanatomy.”

Using MRIs or CT scans, surgeons base their decisions on static images, whereas computers have already been shown

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to be accurate in eliminating “outliers,” or deviations from the optimum intended angle, where implants aren’t put in within a few degrees of accuracy. “It takes time to learn,” Dr. Kingston says, “and if you’re a busy orthopaedic surgeon it’s hard to justify another 15-20 minutes per case.” But he and his partners have been working with computer navigation for five years, and today they can perform surgeries much quicker and more efficiently – and with stunning accuracy – than when using standard instrumentation.

arthroSCopIC teChnIqueS“Our doctors are doing incredible surgeries with minimally

invasive arthroscopic techniques of every joint,” says Dr. Campolattaro. And new physician Dr. Nicholas Sablan is bringing a level of sophistication for hip arthroscopy only typically seen in major centers in major cities. In his fellowship, Dr. Sablan will do more than 200 hip arthroscopies, making him one of the busiest hip arthroscopists in the nation – adding another degree of sophistication that’s not usually seen in a small city like Hampton.

Tidewater Ortho physicians like to boast that there’s no joint in the body they don’t have specialists dedicated to. “There’s no other orthopaedic surgery group on the peninsula that can say that,” says Dr. Campolattaro.

For the Tidewater Ortho surgeons, the completion of their three-plus year vision of a full service specialized facility at the Orthopaedic Hospital at Sentara CarePlex represents

New technology has made it possible for orthopaedic surgeons to navigate joint replacement procedures with a level of accuracy so precise it may actually improve the results of surgery.1 Stryker’s computer-assisted surgery can help your surgeon work more efficiently with less invasive techniques and help align implants to your unique anatomy.

To learn more about Computer-Assisted Surgery and locate Stryker specialists in your area, visit www.aboutStryker.com or call 1.888.STRYKER.

Suffer from Knee Pain?Stryker’s computer-assisted technology is like having a global positioning system (GPS) in the operating room.

The information presented is for educational purposes only. Please speak to your doctor to decide if joint replacement surgery is right for you. Individual results vary and not all patients will receive the same post-operative activity level. Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: Stryker. All other trademarks are trademarks of their respective owners or hold-ers. 1. Sikorski JM, Chauhan S. Computer-Assisted Orthopaedic Surgery: Do we need CAOS? JBJS 2003; 85-B:319-23. Copyright © 2010 Stryker. All rights reserved.

more than just the opportunity to provide an unparalleled level of surgical care for their orthopaedic patients. “For us, it’s always been about serving our patients’ total needs,” says Dr. Kingston. “That’s why we’ve done all this work – that’s why we’ve spent these three years putting it all together. It’s about the patient’s total experience – that’s the bottom line.”


James L. Phillips*, MD / TraumaJames Phillips, MD, FAAOS, is a Board-certified orthopaedic surgeon. He completed his residency at the Johns Hopkins School and served with the U.S. Navy Staff at the Naval Medical Center in Bethesda, Maryland. Dr. Phillips was co-founder of Tidewater Ortho and is a member of the Orthopaedic Trauma Association.

Loel Z. Payne*, MD / Shoulder and KneeLoel Payne, MD, FAAOS, is a Board-certified, orthopaedic surgeon. He completed a fellowship in shoulder surgery and sports medicine at the Hospital for Special Surgery in New York. He has written multiple articles and book chapters and lectured nationally on shoulder conditions.

Colin M. Kingston*, MD / Sports Medicine and Joint ReplacementsColin Kingston, MD, FAAOS, is a Board-certified, orthopaedic surgeon. He completed medical school and his residency while serving in the United States Air Force. He has served in both gulf wars in Operation Southern Watch, Operation Enduring Freedom and Iraqi Freedom. Dr. Kingston serves as the Orthopaedic Medical Director of the region’s only dedicated orthopaedic hospital

Robert M. Campolattaro*, MD / Hand, Wrist and ElbowRobert Campolattaro, MD, FAAOS, CAQSH, is a Board-certified, orthopaedic surgeon. He completed a fellowship in hand and upper extremity at Wake Forest University Baptist Medical Center and has a practice that solely focuses on the treatment of hand, wrist, and elbow conditions.

Paul E. Savas*, MD / SpinePaul Savas, MD, FAAOS, is a Board-certified orthopaedic surgeon. He completed a fellowship in spine surgery at Jefferson Medical College of Thomas Jefferson University and has written and presented numerous articles on the spine and treatment of spine-related conditions. His practice focuses on the treatment of the spine.

“The Specialists Group”

* Board Certified Orthopaedic Surgeon | FAAOS - Fellow of the American Academy of Orthopaedic SurgeonsCAQSH - Certificate of Added Qualifications in Surgery of the Hand

AACFAS - Associate of the American College of Foot and Ankle SurgeryDAAOS - Diplomate of the American Academy of Orthopaedic Surgeons

Michael E. Higgins*, MD / Joint Replacements and ReconstructionMichael Higgins, MD, FAAOS, is a Board-certified, orthopaedic surgeon. He completed a fellowship in joint replacement and reconstruction at the Roanoke Orthopaedic Center. He has written articles and lectured on hip and knee replacement.

Nicholas A. Smerlis*, MD / Hand, Wrist and ElbowNicholas Smerlis, MD, FAAOS, CAQSH, is a Board-certified, orthopaedic surgeon with subspecialty certification in surgery of the hand. He completed a fellowship in hand and upper extremity at Wake Forest University Baptist Medical Center and has a practice that solely focuses on the treatment of hand, wrist, and elbow conditions.

John J. McCarthy III*, MD / Joint Replacement and General OrthoJohn McCarthy, MD, FAAOS, is a Board-certified orthopaedic surgeon. He completed a fellowship in hand surgery at the Hand Rehabilitation Center –in Philadelphia, PA. and served as a team physician for Pittsburgh Penguins professional hockey team.

Sara M. Bouraee, DPM / Foot and Ankle Sara Bouraee, DPM, AACFAS is a Board-qualified podiatric surgeon (foot and rear foot/ankle). She completed her residency at Drexel University College of Medicine/Hahnemann University Hospital where she also served as Chief Resident (Foot and Ankle Surgery).

Nick Sablan, MD / Sports MedicineNick Sablan, MD, an orthopaedic surgeon who completed a fellowship in orthopaedic sports medicine at Kerlan Jobe Clinic in Los Angeles, and has served as assistant team physician for the Los Angeles Lakers, the LA Dodgers, the LA Angels, the PGA Tour, among others. He is the author of published multimedia, peer-reviewed publications and a book chapter on arthroplasty of the hip.


Tidewater Ortho is proud to introduce

its newest surgeon, Dr. Nick Sablan.

Dr. Sablan is a graduate of the

University of Notre Dame, and earned his

medical degree at the Albert Einstein College

of Medicine in the Bronx. He completed

his residency in orthopaedic surgery at the

University of Connecticut, and a fellowship

in orthopaedic sports medicine in the Kerlan

Jobe Clinic in Los Angeles.

In Los Angeles, he served as assistant

team physician to virtually all of the area’s

professional sports teams: the Lakers and

the Sparks (basketball), the LA Kings and

the Anaheim Ducks (ice hockey), the Los

Angeles Dodgers and the Angels (baseball),

and the PGA Tour. In addition, he worked

with athletes from college and high school

sports teams, and while he enjoyed going to

spring training with the major leaguers this

year – hanging out and eating breakfast with

them – he finds working with college age and

younger athletes more enjoyable.

It may well have been his own youthful

basketball career that inspired his choice

of sports medicine and orthopaedics. Dr.

Sablan states that his athletic career peaked

in high school; however, life as a physician

helping others was something he says he

could visualize every day. That vision was

partially formed by his parents, both of whom

are physicians. His father is an internist, his

mother a family practitioner. “I so respected what they

both did,” he says, “and I loved science and technology.

Medicine seemed like a natural progression for me, which

would allow me to pursue everything I loved.”

Dr. Sablan and his wife, a teacher, were deciding whether

to stay in California, or return to the east coast, where

her family lives in Northern Virginia. As 21st century

professionals, they did much of their job searching online,

where Dr. Loel Payne found his curriculum vitae.

The two “met” online, and Dr. Payne invited Dr. Sablan

to come to Hampton Roads to look at the practice and the

Introducing Nick Sablan, MD

community. “When we first came here,” he remembers,

“it impressed us. It was a beautiful place – good weather,

good schools, good people – and a great practice.”

Dr. Sablan was immediately struck by the Tidewater

Ortho philosophy – each physician concentrating on a

focused subspecialty area within orthopaedic surgery.

He’s looking forward to the opportunity of using his

extensive sports medicine knowledge. He will bring to the

Tidewater region the ability to perform hip arthroscopies,

which is an expanding, technically difficult procedure

rarely done in this area.

By Prue Salasky Surgeons Get Big Thumbs Up

Nick Smerlis, MD can’t contain a grin. Every time he sees patient Patrick Smith, the hand surgeon breaks out in a smile. “I couldn’t have hoped for a better

result,” says Smerlis, who reattached Smith’s completely severed right thumb eleven months ago.

A long-time construction worker, Smith was operating a 12-inch miter box saw on the afternoon of June 15 when he reached across it to grab the piece of wood. He saw the blade hit something but didn’t feel anything. “Generally when the blade comes down, the guard goes up. It didn’t work,” he says. He saw the blood and responded rapidly, retrieving his thumb from the pile of wood chips, wrapping his hand and the thumb in an old T-shirt and calling on his son Steven, who was working with him, to drive him to the nearby Sentara CarePlex. He didn’t tell him the extent of the injury so as not to alarm him. In less than 10 minutes Smith was in the emergency room, and he and his thumb were being prepped separately for surgery.

Smith was fortunate on a couple of counts. “Ninety-eight percent of the time I’m by myself in the middle of nowhere,” he says. This day he had a whole work crew with him — who cleaned up the blood at the site and repainted — and he was also in close proximity to the hospital and highly qualified hand surgeons.

Smerlis and Robert Campolattaro are the only two board-certified surgeons in the region with a CAQ, or certificate

of added qualification, in hand surgery; they practice with Tidewater Orthopaedic Associates. Led by Smerlis, they called on all their expertise for the complex procedures necessary to restore function to Smith’s thumb. These included fracture work, stabilizing bone, revascularization, fixing the nerves and tendons, and dealing with soft tissue. “Its uniqueness in a small area of someone’s body gels hand surgery into a nutshell,” says Smerlis. It’s the first such surgery he’s performed in the four years since he came to the area and the first outside an academic setting where the resources are typically far greater. “It’s not an everyday

event,” he adds. After a 6-hour surgery, in which Smerlis

shortened the thumb to reduce the nerve length and ease the attachment, there were several critical junctures that Smith had

to overcome. In the first 24 hours the inflow artery connection to sup-

ply blood is critical so the thumb doesn’t die; after that, the outflow becomes key as there’s a tendency to venous congestion. Smith had one good vein and one not so good with a flap of skin disrupting it. After a few days, Smith had a leech attached to his wound four

times a day for 45 minutes to an hour to ensure his

(L-R) Patrick Smith, certified hand therapist

Terri Shipley, and Nick Smerlis, MD

Smith is making remarkable progress; he can even pick up slippery little beads, one by one, and drop them through a small hole into a container


thumb didn’t suffer congestion. “It didn’t bother me,” says Smith. “Some of the nurs-es were squeamish; others treated the leech-es like pets.” His young sons, aged 13 and 16, found the process hilarious, videotaped it and posted the grisly scene on YouTube. After 10 days in the hospital, most spent in intensive care with the thumb kept warm in a “tent” with hot air blowing on it, Smith returned home. Though he’s not yet back to work, he confesses that he’s already used a saw again. He also works on his sons’ Mo-tocross bikes.

For the first couple of months his therapy sessions consisted mainly of wound care and splinting. Now, in biweekly sessions with certified hand therapist Terri Shipley, he works on improving strength and function. “There’s about a 40 percent survival rate for a thumb. Usually it’s ‘just sort of there,’” says Shipley. “It takes about six weeks for nerves to regenerate, to even connect and get any feeling.”

She puts Smith, 58, through his paces, having him knead a mound of purple putty with a key device. In between, he bends the tip of his right thumb back and forth — “To

get the tip movement is unbelievable,” says Shipley. Smith, whose thumb is fused at the MP level where the thumb joins the hand, then demonstrates sufficient dexterity to thread a fiddly nut onto a bolt — a task that a month ago he couldn’t even contemplate. He’s also able to grasp a tension-filled clothespin and move it from one object to another. He can even pick up slippery little beads, one by one, and drop them through a small hole into a container.

“I’m getting a lot of feeling back rather quickly,” says Smith, showing a burn mark down one side of the shortened, red digit. He incurred that injury a few weeks ago, before he had regained any feeling in the thumb. He still tends to drop things, not having sufficient feeling to grasp items securely.

Shipley anticipates another month of therapy and observes that he can already snap his fingers and touch his little finger to his thumb. “It will take almost a year to determine how much protective sensation — hot/cold, sharp/dull — he will regain,” says Smerlis. Meanwhile, his sensitivity to cold is a typical reaction to nerve injury.

Shipley praises Smith’s attitude, his calm and his compliance. An important element of the successful re-implant of his thumb required him to quit smoking cold turkey. “Smoking’s a huge no-no. It causes spasms,” says Shipley. At the time, Smith had a half-a-pack-a-day habit. He also had to forego caffeine for several weeks. Smith doesn’t anticipate much restriction in his future activities, though he’ll no longer be able to donate blood because he received a transfusion. Otherwise, “It gets better every day,” he says.

Tidewater Ortho would like to thank the Daily Press for providing permission to reprint this story that was published on November 10, 2010. The author, Prue Salasky can be reached at psalasky@daily press.com or 274-4784


By Sara Bouraee, DPM Our Poor Ankles

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Running: the steady pounding of your body weight added to the force of gravity applied to one ankle at a time. What is the difference between running

and walking? The answer is the gait cycle or the positions our joints move through as we walk or run. While walking, body weight is distributed among two feet at a time. While running, body weight is being carried by one foot at a time.

Why are the effects of running and walking so different on your ankles? To understand the answer, you must factor in gravity and force. Each step you take while running is two to three times your body weight. All of this pressure is transmitted through one ankle. This pressure can overwhelm your ankles, causing pain, poor running performance, or even a situation where your ankle gives out and you fall.

Your ankle takes a beating; two to three times of your body weight on one ankle joint about 2600 times per hour. The ankle joint is made up of three bones: two leg bones (the fibula and the tibia) and one foot bone (the talus). Your ankle is the sole joint that transfers vertical force into horizontal force. The motion of your ankle keeps you moving forward, and moving forward is the key to running. Your poor ankle – no wonder it’s prone to injury, stress and pain sometimes!

So the question is, what can you do to make it stop hurting? Stopping running is one way, but any avid runner will only see that as a last resort. For many runners, it would destroy their psyches to stop! You run for peace of mind, you run for your health, you run for you. Running is part of who you are. I understand that!

There are other things you can do to help you continue to run and decrease your pain level. The most common reason runners have pain in their ankle joint is because they do not stretch enough, or do not stretch properly. You must stretch your ilio-tibial band, and stretch your Achilles tendon. Don’t forget to stretch your hamstrings, your quadriceps, and your hip flexors.

Another common reason for ankle pain is arthritis. Ibuprofen is not the answer for runners: non-steroidal anti-inflammatory medication (NSAIDs) taken while running can shut down the kidneys. Instead, try icing the joints to decrease the inflammation.

Another thing you can do is get a steroid injected into your ankle joint. This is not a cure for the problem, but it is a pretty good band-aid. It will help in the short term and get you back to training. There are some long term options,


Sara Bouraee, DPM, is a Board-qualified podiatric surgeon (foot and rear foot/ankle) with Tidewater Ortho. She completed her residency at Drexel University College of Medicine/Hahnemann University Hospital where she also served as Chief Resident (Foot and Ankle Surgery).

such as ankle arthroscopy or other surgical procedures, but they will keep you away from training for several weeks.

Another common problem in runners is hyper-pronation of the foot, where the arch falls. The arch falls lower and faster while running compared to walking. A custom made orthotic is the best way to prevent the arch from falling. The orthotic holds up the arch and allows the leg muscles to function more efficiently.

Efficient muscle use translates into less oxygen consumption, which makes the runner feel less tired. This ultimately means more productive muscle use and more efficient running. We all want to run better, run longer, and run faster. The best way to do this is by educating yourself on your body and what your body needs.

Take the Pledge and become an

advocate for sports safety.

Visit www.STOPSportsInjuries.org

Facebook.com/STOPSportsInjuries

Twitter.com/SportsSafety

Join us today

Founding supporters of the campaign include: the American Orthopaedic Society for Sports Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, National Athletic Trainers’ Association, National Strength and Conditioning Association, American Medical Society for Sports Medicine, Sports Physical Therapy Section, Pediatric Orthopaedic Society of North America and SAFE Kids USA.

The STOP Sports Injuries campaign educates athletes, parents, trainers, coaches and healthcare providers about the rapid increase in youth sports injuries, especially related to overuse and trauma. Featuring a website with social media, blogs, public service announcements and a multitude of sport specific resources, the campaign strives to keep kids injury free and in the game for life.

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Groin pain in the athlete is a fairly common presenting complaint for many athletes of all sizes and shapes. Sports involving rotation, such as baseball and golf,

often have coexisting problems of groin pain and lower back pain. Most athletes present with a “groin strain” either from an acute event or more gradual symptoms that have not responded to rest, anti-inflammatory medications, stretching or activity modification. It is often important to determine that the athlete does not have a sports hernia (also known as athletic pubalgia), bursitis, snapping hip syndrome (where the hip flexor tendon literally snaps across the bony prominence), and referred pain from an underlying back problem. One of the newer recognized causes of hip pain in athletes is femoral acetabular impingement.

Femoral acetabular impingement (FAI) is basically when an abnormal shape of the bones of the hip joint leads to premature damage to the cartilage. More specifically, the ball or femoral head has a bony prominence, causing a cam effect. Also, there can be abnormal spurring at the edge of the cup

or acetabulum leading to the pincer effect. There can be a combination of both. The abnormal shape of the bone then causes the labrum (a thick rubbery liner of the hip) to be torn, which in turn can lead to injury of the articular cartilage, thus premature osteoarthritis in the hip. There are many theories as to the cause of the abnormal shape or morphology of the bone. One such theory suggests that intense physical activity in the young athlete can lead to premature closure of part of the growth plate, causing an abnormal shaped bone which leads to cartilage damage with repetitive high impact motion. This implies that early arthritis in adults may actually start to occur in childhood. Symptoms, however, do not become prevalent until young adulthood. The symptomatic athlete will often compensate for decreased flexibility in the hip by increasing pelvic and lower back motion. This may lead to concomitant lower back pain, bursitis, gluteal pain or adductor muscle tenderness, which may blur the primary cause of these symptoms. The athlete with FAI will often complain of groin and buttock pain that radiates to the medial thigh, and place a hand in the shape of a “C” over the lateral aspect of the hip. The “C” sign combined with a history of catching, sharp intermittent pain associated with pivoting, twisting or turning all suggest FAI.

The findings on physical examination for FAI typically will include pain with maximum flexion of the hip, pain with the hip flexed at 90 degrees and internal rotation of the leg

By Colin Kingston, MD Groin Pain in the Athlete: Femoral Acetabular Impingement


Colin Kingston, MD, is a Board-certified, orthopaedic surgeon with Tidewater Ortho. He completed medical school and his residency while serving in the United States Air Force. He has served in both gulf wars in Operation Southern Watch, Operation Enduring Freedom and Iraqi Freedom. Dr. Kingston has written a chapter for a review course for orthopaedic surgeons to become board certified and currently serves as the Orthopaedic Medical Director of the region’s only dedicated orthopaedic hospital.

with adduction (also known as the impingement test), and pain with log rolling the leg (going from internal to external rotation with the leg straight). Tenderness with resisted hip flexion, sit-ups, or hip adduction goes more along with a sports hernia. Tenderness with the hip flexed and externally rotated, bringing down into extension and internal rotation with an audible snap, is more consistent with snapping hip syndrome. X-rays of the hip should be obtained and often can demonstrate the abnormal morphology for FAI.

Additional studies such as an MRI may be warranted. The MRI needs to be at least 1.5 Telsa strong (most open scanners and small magnets are ineffective for diagnosis) with the use of surface coils. The sensitivity to detect labral tears and other intra-articular pathology is enhanced with injecting dye called gadolinium (GAD) into the joint prior to the MRI. The GAD injection should be accompanied by a concomitant local anesthetic injection, which will also be able to determine if all of the athlete’s symptoms are actually occurring within the hip joint. A 3-dimensionsal CT scan may be ordered to assess the extent of the bony abnormality, and is useful for pre-operative planning when resection is warranted.

The indications for surgical intervention are persistent groin pain in an athlete who has failed non-operative treatment, who has a cam and/or pincer lesion confirmed

with diagnostic testing, and who has had at least temporary relief of the intra-articular anesthetic injection, confirming that the symptoms are coming from the hip joint and not referred. Hip arthroscopy and anterior hip incisions are the two most common techniques to address this problem. Both have had varying success, with hip arthroscopy gaining in popularity as the techniques become more refined. I constantly strive to improve my hip arthroscopic techniques to enhance my patients’ functional outcomes.

The key to managing FAI is early detection in order to prevent often times devastating consequences of premature arthritis and career ending hip pain.


By Loel Payne, MD Specialization: What Does it Mean?

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I recently had the opportunity of seeing a patient in my office who

I had not seen in 15 years. I recognized her name immediately on

my list of patients for the day. There are some people because of

their personality, or disease, or recovery process that you just can’t

forget. In this case, she was a 15 year old girl whose hand had

been partially severed by a knife. There was serious concern that

she might lose part of her hand, or at the least have stiff and

crooked fingers for the rest of her life. In the mid 1990s, we were

just starting to evolve into orthopaedic specialization in Hampton

Roads. Most orthopaedic surgeons did general orthopaedics. They

were responsible for everything that came through their door (or in this case,

through the Emergency Room). I took the young girl to the operating room and

despite much angst and sweat on my part, repaired her hand to the best of my

ability. Fortunately, when I saw her again at age 30 with 2 small children in tow,

her hand worked well with only minimal scars. In retrospect, I must admit that I

probably got lucky. I had learned hand surgery as a resident, but wasn’t prepared

for the complexities occasionally encountered.

According to the AMA guide for CPT surgical coding, there are close to 1500

surgical procedures just for orthopaedics. During your five year orthopaedic

resident training, you are expected to learn almost all of them. However,

educational psychologists have shown it requires 10,000 hours of intense

practice to become an expert. We all know that the more you do one thing,

the better you become. I don’t believe you can do a good job each time when

you’re fixing a hand in one case, a

spine the next, a minimally invasive

hip replacement after that, followed

by an arthroscopic shoulder repair.

I have now narrowed my practice

to primarily shoulder and knee

disorders. I currently perform

about 100 of the 1500 surgeries I

learned as a resident. Of these 100

surgeries, only 3 or 4 are done the

same way I was taught in the early

1990s. Orthopaedics has grown

rapidly in the last 10-15 years,

with expanding technology and

improved monitoring of clinical

outcomes. It is difficult to stay

abreast of the changes in one area


of orthopaedics, much less the entire field. To learn the

latest techniques and understand the current treatments

requires a considerable time investment.

Tidewater Ortho started our concept of orthopaedic

physician specialization over 15 years ago. We have been

able to recruit surgeons with specialization in hand, spine,

joint replacement, shoulder, foot/ankle, trauma and sports

medicine. Our specialists have completed an additional

year of training after their residency in their area of

expertise (fellowship), completed a national credentialing

process as an expert (Certificate

of Added Qualification), or have

become members of specialized

societies with a focus of their

continued education in this sub-

specialty. You can see from the

articles in this publication the

complexity of disorders we are

able to treat. We are fortunate

to add Dr. Nicholas Sablan to

our group later this year; he will

expand our specialization in

sports medicine. He is currently

helping treat players on the Los

Angeles Lakers, Dodgers and

Kings, as well as USC football.

We have also partnered with

the Orthopaedic Hospital at

Sentara, a specialized hospital

dedicated to the exclusive

treatment of orthopaedic

disorders. This facility has

anesthesiologists with special

training in regional (“block”)

anesthesia and offers our patients

the best pain relief after their

surgeries. The operating room

staff and nurses are dedicated

to treating orthopaedic patients

and manage them routinely.

The inpatient floor nurses love

orthopaedics, and it shows in

the very high patient satisfaction

scores. The advanced operating rooms are equipped for

only orthopaedic surgery, and have the latest advanced

technology, such as computer assisted joint replacements

We believe that to provide the best care to our patients, all physicians must critically ask themselves if there is someone else who could do a better job with an operation.

“Why get a total knee if you only need a ?”

Mary Lou Retton

1984 Olympic Gold Medalist Paid Spokesperson and Biomet Hip Replacement Recipient.

Ask your doctor about the Oxford® Partial Knee.

Now there’s an alternative to total knee replacement. The Oxford® Partial Knee from Biomet. It’s the only one of its kind in the United States. The Oxford® Partial Knee lets you keep up to 75% of your healthy knee — for a more rapid recovery with less post-operative pain and more natural motion. Why get a total knee when maybe all you need is a partial knee from Biomet? To learn more, or to find an Oxford® Knee trained surgeon in your area, call or visit our website.

oxfordknee.com/FL I 800.581.8169

Not all patients are candidates for partial knee replacement. Only your orthopedic surgeon can tell you if you’re a candidate for joint replacement surgery, and if so, which implant is right for your specific needs. You should discuss your condition and treatment options with your surgeon. The Oxford® Meniscal Partial Knee is intended for use in individuals with osteoarthritis or avascular necrosis limited to the medial compartment of the knee and is intended to be implanted with bone cement. Potential risks include, but are not limited to, loosening, dislocation, fracture, wear, and infection, any of which can require additional surgery. For additional information on the Oxford® knee, including risks and warnings, talk to your surgeon and visit Biomet.com. © 2011 Biomet Orthopedics, Inc.


Loel Payne, MD, is a Board-certified, orthopaedic surgeon with Tidewater Ortho. He completed a fellowship in shoulder surgery and sports medicine at the Hospital for Special Surgery in New York. He has written multiple articles and book chapters and lectured nationally on shoulder conditions.

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TM

and anterior (jiffy) hip replacement. Other types of

surgery cases and infections are not allowed in these

operating rooms, which has allowed us to maintain one

of the lowest infection rates in the state. This concept of

specialization at the hospital level blends well with our

own practice philosophy and aids in the ability to provide

our patients with the best possible care.

Fortunately, today, I would not have to manage the

complex hand injury I described earlier. I have two well

trained hand specialists available who are on call everyday.

We believe that to provide the best care to our patients, all

physicians must critically ask themselves if there is someone

According to the AMA guide for CPT surgical coding, there are close to 1500 surgical procedures just for orthopaedics. During your five year orthopaedic resident training, you are expected to learn almost all of them. However, educational psychologists have shown it requires 10,000 hours of intense practice to become an expert.

else who could do a better job with an operation. Within

our group, we are fortunate to have specialists in many areas

and we routinely refer patients to someone else with more

expertise in managing their problem. This may require a

patient seeing another doctor on a different day, but the

extra time will be worth the benefit of seeing a specialist.

If you’re an adult who suffers from Dupuytren’s contracture with a “cord” that can be felt, or have a patient that does, surgery is not the only option: XIAFLEX is another choice.

• The only FDA-approved nonsurgical option for this condition

• In-office procedure

• 91% of insured patients now have access1

© 2011 Auxilium Pharmaceuticals, Inc. 0211-002.a

XIAFLEX (collagenase clostridium histolyticum) is a prescription medicine used to treat adults with Dupuytren’s contracture when a “cord” can be felt. In people with Dupuytren’s contracture, there is an abnormal thickening of the skin and tissue of the palm that can form a cord over time. This cord can cause one or more fingers to bend toward your palm, so that the finger(s) cannot be straightened. XIAFLEX should be injected into the cord by a healthcare provider who is experienced in injection procedures of the hand and treating people with Dupuytren’s contracture. XIAFLEX helps to break down the cord that is causing the finger to be bent.

IMPORTANT SAFETY INFORMATIONXIAFLEX can cause serious side effects, including:

•Tendon or ligament damage. Receiving an injection of XIAFLEX may cause damage to a tendon or ligament in your hand and cause

it to break or weaken. This could require surgery to fix the damaged tendon or ligament. Call your healthcare provider right away if you have trouble bending your injected finger (towards the wrist) after the swelling goes down or you have problems using your treated hand after your follow-up visit.

•Nerve injury or other serious injury of the hand. Call your healthcare provider if you get numbness, tingling, or increased pain in your treated finger or hand after your injection or after your follow-up visit.

•Allergic Reactions. Allergic reactions can happen in people who have received an injection of XIAFLEX because it contains foreign proteins. Call your healthcare provider right away if you have any of these symptoms of an allergic reaction after an injection of XIAFLEX: hives; swollen face; breathing trouble; or chest pain.

Before receiving XIAFLEX, tell your healthcare provider if you have had an allergic reaction to a previous XIAFLEX injection, or have a bleeding problem or any other medical conditions. Tell your healthcare provider about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. Be sure to tell them if you use blood thinners such as aspirin, clopidogrel (Plavix®), prasugrel hydrochloride (Effient®), or warfarin sodium (Coumadin®).

Common side effects with XIAFLEX include: swelling of the injection site or the hand, bleeding or bruising at the injection site; and pain or tenderness of the injection site or the hand, swelling of the lymph nodes (glands) in the elbow or underarm, itching, breaks in the skin, redness or warmth of the skin, and pain in the underarm.

Please see the Important Product Information on adjacent page. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.FDA.gov/medwatch, or call 1-800-FDA-1088. Plavix® is a registered trademark of sanofi-aventis/Bristol-Myers Squibb. Effient® is a registered trademark of Eli Lilly and Company. Coumadin® is a registered trademark of Bristol-Myers Squibb.

Reference: 1. Data on file. Auxilium Pharmaceuticals, Inc.

Explore all of your options. Consider XIAFLEX. Go to XIAFLEXbenefits.com or call 1-877-XIAFLEX

(1 -877 -942 -3539)

Think

4003_RGA_tidewater_ortho_4C_042911.indd 1 5/4/11 1:03 PM

Important Product Information XIAFLEX® (Zï a flex) (collagenase clostridium histolyticum)

What is the most important information I should know about XIAFLEX?

XIAFLEX can cause serious side effects, including:

• Tendon or ligament damage. Receiving an injection of XIAFLEX may cause damage to a tendon or ligament in your hand and cause it to break or weaken. This could require surgery to fix the damaged tendon or ligament. Call your healthcare provider right away if you have trouble bending your injected finger (towards the wrist) after the swelling goes down or you have problems using your treated hand after your follow-up visit.


•Allergic Reactions. Allergic reactions can happen in people who take XIAFLEX because it contains foreign proteins.

Call your healthcare provider right away if you have any of these symptoms of an allergic reaction after an injection of XIAFLEX:

• hives • swollen face • breathing trouble • chest pain

What is XIAFLEX?

XIAFLEX is a prescription medicine used to treat adults with Dupuytren’s contracture when a “cord” can be felt.

In people with Dupuytren’s contracture, there is thickening of the skin and tissue in the palm of your hand that is not normal. Over time, this thickened tissue can form a cord in your palm. This causes one or more of your fingers to bend toward the palm, so you can not straighten them.

XIAFLEX should be injected into a cord by a healthcare provider who is skilled in injection procedures of the hand and treating people with Dupuytren’s contracture. The proteins in XIAFLEX help to “break” the cord of tissue that is causing the finger to be bent.

It is not known if XIAFLEX is safe and effective in children under the age of 18.

What should I tell my healthcare provider before starting treatment with XIAFLEX?

XIAFLEX may not be right for you. Before receiving XIAFLEX, tell your healthcare provider if you:

• have had an allergic reaction to a previous XIAFLEX injection.

• have a bleeding problem. • have any other medical conditions. • are pregnant or plan to become

pregnant. It is not known if XIAFLEX will harm your unborn baby.

• are breastfeeding. It is not known if XIAFLEX passes into your breast-milk. Talk to your healthcare provider about the best way to feed your baby if you receive XIAFLEX.

Tell your healthcare provider about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements.

Especially tell your healthcare provider if you use:

a blood thinner medicine such as aspirin, clopidogrel (PLAVIX®), prasugrel hydrochloride (EFFIENT®), or warfarin sodium (COUMADIN®). If you are told to stop taking a blood thinner before your XIAFLEX injection, your healthcare provider should tell you when to restart the blood thinner.

How will I receive XIAFLEX?

Your healthcare provider will inject XIAFLEX into the cord that is causing your finger to bend.

After an injection of XIAFLEX, your affected hand will be wrapped with a bandage. You should limit moving and using the treated finger after the injection.

Do not bend or straighten the fingers of the injected hand until your healthcare provider says it is okay. This will help prevent the medicine from leaking out of the cord.

Do not try to straighten the treated finger yourself.

Keep the injected hand elevated until bedtime.

Call your healthcare provider right away if you have:

• signs of infection after your injection, such as fever, chills, increased redness, or swelling

• numbness or tingling in the treated finger • trouble bending the injected finger after

the swelling goes down Return to your healthcare provider’s office as directed on the day after your injection. During this first follow-up visit, if you still have the cord, your healthcare provider may

try to extend the treated finger to “break” the cord and try to straighten your finger.

Your healthcare provider will provide you with a splint to wear on the treated finger. Wear the splint as instructed by your healthcare provider at bedtime to keep your finger straight.

Do finger exercises each day, as instructed by your healthcare provider.

Follow your healthcare provider’s instructions about when you can start doing your normal activities with the injected hand.

What are the possible side effects of XIAFLEX?

XIAFLEX can cause serious side effects. See “What is the most important information I should know about XIAFLEX?”.

Common side effects with XIAFLEX include:

• swelling of the injection site or the hand • bleeding or bruising at the injection site • pain or tenderness of the injection site or

the hand • swelling of the lymph nodes (glands) in

the elbow or underarm • itching • breaks in the skin • redness or warmth of the skin • pain in the underarm

These are not all of the possible side effects with XIAFLEX. Tell your healthcare provider about any side effect that bothers you or does not go away.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

General information about XIAFLEX

Medicines are sometimes prescribed for purposes other than those listed here. This is a summary of the most important information about XIAFLEX. If you would like more information, talk to your healthcare provider. You can ask your healthcare provider for information about XIAFLEX that is written for health professionals.

For more information visit www.XIAFLEX.com or call 1-877-663-0412.

© 2011 Auxilium Pharmaceuticals, Inc. For US residents only.

40 Valley Stream Parkway Malvern, PA 19355 www.auxilium.com

072010

Important Product Information XIAFLEX® (Zï a flex) (collagenase clostridium histolyticum)

What is the most important information I should know about XIAFLEX?

XIAFLEX can cause serious side effects, including:

• Tendon or ligament damage. Receiving an injection of XIAFLEX may cause damage to a tendon or ligament in your hand and cause it to break or weaken. This could require surgery to fix the damaged tendon or ligament. Call your healthcare provider right away if you have trouble bending your injected finger (towards the wrist) after the swelling goes down or you have problems using your treated hand after your follow-up visit.


•Allergic Reactions. Allergic reactions can happen in people who take XIAFLEX because it contains foreign proteins.

Call your healthcare provider right away if you have any of these symptoms of an allergic reaction after an injection of XIAFLEX:

• hives • swollen face • breathing trouble • chest pain

What is XIAFLEX?

XIAFLEX is a prescription medicine used to treat adults with Dupuytren’s contracture when a “cord” can be felt.

In people with Dupuytren’s contracture, there is thickening of the skin and tissue in the palm of your hand that is not normal. Over time, this thickened tissue can form a cord in your palm. This causes one or more of your fingers to bend toward the palm, so you can not straighten them.

XIAFLEX should be injected into a cord by a healthcare provider who is skilled in injection procedures of the hand and treating people with Dupuytren’s contracture. The proteins in XIAFLEX help to “break” the cord of tissue that is causing the finger to be bent.

It is not known if XIAFLEX is safe and effective in children under the age of 18.

What should I tell my healthcare provider before starting treatment with XIAFLEX?

XIAFLEX may not be right for you. Before receiving XIAFLEX, tell your healthcare provider if you:

• have had an allergic reaction to a previous XIAFLEX injection.

• have a bleeding problem. • have any other medical conditions. • are pregnant or plan to become

pregnant. It is not known if XIAFLEX will harm your unborn baby.

• are breastfeeding. It is not known if XIAFLEX passes into your breast-milk. Talk to your healthcare provider about the best way to feed your baby if you receive XIAFLEX.

Tell your healthcare provider about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements.

Especially tell your healthcare provider if you use:

a blood thinner medicine such as aspirin, clopidogrel (PLAVIX®), prasugrel hydrochloride (EFFIENT®), or warfarin sodium (COUMADIN®). If you are told to stop taking a blood thinner before your XIAFLEX injection, your healthcare provider should tell you when to restart the blood thinner.

How will I receive XIAFLEX?

Your healthcare provider will inject XIAFLEX into the cord that is causing your finger to bend.

After an injection of XIAFLEX, your affected hand will be wrapped with a bandage. You should limit moving and using the treated finger after the injection.

Do not bend or straighten the fingers of the injected hand until your healthcare provider says it is okay. This will help prevent the medicine from leaking out of the cord.

Do not try to straighten the treated finger yourself.

Keep the injected hand elevated until bedtime.

Call your healthcare provider right away if you have:

• signs of infection after your injection, such as fever, chills, increased redness, or swelling

• numbness or tingling in the treated finger • trouble bending the injected finger after

the swelling goes down Return to your healthcare provider’s office as directed on the day after your injection. During this first follow-up visit, if you still have the cord, your healthcare provider may

try to extend the treated finger to “break” the cord and try to straighten your finger.

Your healthcare provider will provide you with a splint to wear on the treated finger. Wear the splint as instructed by your healthcare provider at bedtime to keep your finger straight.

Do finger exercises each day, as instructed by your healthcare provider.

Follow your healthcare provider’s instructions about when you can start doing your normal activities with the injected hand.

What are the possible side effects of XIAFLEX?

XIAFLEX can cause serious side effects. See “What is the most important information I should know about XIAFLEX?”.

Common side effects with XIAFLEX include:

• swelling of the injection site or the hand • bleeding or bruising at the injection site • pain or tenderness of the injection site or

the hand • swelling of the lymph nodes (glands) in

the elbow or underarm • itching • breaks in the skin • redness or warmth of the skin • pain in the underarm

These are not all of the possible side effects with XIAFLEX. Tell your healthcare provider about any side effect that bothers you or does not go away.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

General information about XIAFLEX

Medicines are sometimes prescribed for purposes other than those listed here. This is a summary of the most important information about XIAFLEX. If you would like more information, talk to your healthcare provider. You can ask your healthcare provider for information about XIAFLEX that is written for health professionals.

For more information visit www.XIAFLEX.com or call 1-877-663-0412.

© 2011 Auxilium Pharmaceuticals, Inc. For US residents only.

40 Valley Stream Parkway Malvern, PA 19355 www.auxilium.com

072010

4003_RGA_tidewater_ortho_4C_042911.indd 2 5/4/11 1:03 PM


In the arena of Workers’ Compensation, the respective roles of the injured worker, medical provider and employer must be considered to navigate through some of the basics

for successfully treating this unique patient population. This article will start with the legal guidelines, and then address the employer, the provider and the injured worker.

Workers’ Compensation in the state of Virginia is promulgated by the Virginia Workers’ Compensation Commission. This body maintains an informational website that includes instructional pamphlets, statutes and judicial decisions, and which has been most recently updated to include on line claims filing and forms. The website is accessible at www.vwc.state.va.us.

In Virginia, employers with 3 or more employees are required to offer a panel of three physicians for medical care once they have been notified of an injury. Some employers use specialists; others offer occupational medicine physicians and/or urgent care centers. Initial acute injury evaluation can also be managed through an Emergency Department for the more serious cases. Injury reporting is done at the employer level when the employer representative is notified either verbally or in writing of an injury by the injured worker. Some employers require written notification, generally prompted by the fact that most insurance carriers require documentation of the incident details to include injured worker demographics and described events. Claims intake generally takes 24-48 hours once reported and claims examiners are then assigned to manage the claim, including all treatment authorizations and payments.

Next, a look at the medical providers’ responsibilities when an injured worker presents for care: as medical providers, we are geared towards taking a medical history; however,

By Diana Staats Workers’s Compensation...OR NOT

when faced with an injured worker, it is also incumbent for us to get a detailed account of the injury incident. How did

Our goal in taking care of this patient population is to honestly address and satisfy the work relativity of our diagnosis, followed by the best medical care, while keeping the workers moving forward.


seriously review their daily job activities and discuss them

with both their medical provider and their work supervisor.

What are some of the activities they can participate in while

recuperating? As medical providers, we should continuously

provide these patients with encouragement to be as active as

possible while protecting their recovery.

Paperwork, yes and lots of it. Frustration, yes and often long

months of recovery. Satisfaction, yes and it is arrived at by

taking on this arena with accuracy, honesty and commitment

to the injured worker, and supporting cast of employer and

insurance carrier. But Workers’ Compensation….. Yes…

It can be done and done well. In an effort to streamline

the process for each “cast member”, Tidewater Ortho has

developed our “WorkAbility” Program to educate physicians,

employers and workers of their responsibilities in this arena.

The ultimate goal is to help the individual return back to a

functional lifestyle where he/she is able to contribute from

both a personal and professional standpoint.

the injury occur and what does the injured worker

recall immediately prior to the incident, during

and immediately afterwards? What are

the specific injuries that have resulted, or

that the worker believes are relative to the

incident? Once the incident history, medical

history and clinical exam are concluded

with a diagnosis or pending diagnosis, it

is important for the medical provider to

address causation; this is the reason for

getting the detailed injury incident

specifics. We have to answer the

question of relativity…. “”but

for the injury incident, would

the injured worker’s signs/

symptoms and/or diagnosis

be present.” This conclusion

represents one of the most

important questions in

claims management,

and one that will always come back to the provider if not

answered initially and clearly. As providers formulate a

treatment plan, it is also important to discuss the worker’s

normal job duties and how the injury/injuries may affect

those physical tasks.

Aside from identifying the diagnosis, treatment plan, and

estimated recovery, medical care providers will also be asked

to address work status. What is medically safe and appropriate

given the injury, keeping in mind the functionality of the

worker. Injured workers can generally perform many of

their normal duties with some modifications, so it’s vital to

keep them active and positive towards their importance in

the workplace. And this of course, brings the discussion full

circle, to the injured worker.

The most important part of this maze of red tape is the

heart and soul of the injured worker. Regardless of how the

incident occurred, the worker now faces an interruption

in the daily activity that we all take for granted as we come

and go each day. Whether the injury is major or minor, to

each worker it is personal – and that makes it serious. The

ramifications of medical treatment, work capacity and future

earning potential all come to bear as the worker faces the

injury and begins to work towards restoration.

Our goal in taking care of this patient population is

to honestly address and satisfy the work relativity of our

diagnosis, followed by the best medical care, while keeping

the workers moving forward. We want to encourage them to

consider their medical treatment as part of the job, have them

Diana Staats, RN, COHN/CM serves as the Director of WorkAbility program for Tidewater Ortho. She is a Registered Nurse with over 30 years of experience primarily in the specialties of Emergency and Occupational Nursing, as well as Case Management. She is certified by the American Board of Occupational Health Nurses in Occupational Health and Case Management.

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Orthopaedics: A Tidewater Update

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