May 10, 2016

Interview Transcript

Dr. Miller: Repair of complex intra-articular fractures, we're going to talk about that next on The Scope.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: I'm here with Thomas Higgins. He is a Professor of Orthopedic Surgery and a Trauma Surgeon Specialist. Thomas, tell us a little bit about what an intra-articular fracture is.

Thomas: It's a fracture that goes into the cartilage, which is the smooth gliding surface of a joint. If a fracture goes into the joint, it disrupts the cartilage. Cartilage doesn't heal as well as many of our other tissues and the long-term problem for the patient is loss of range of motion, swelling and pain in the joint, if it's not properly . . .

Dr. Miller: So this doesn't necessarily happen to people who are just walking or running too much. This sounds like a traumatic injury from some forceful event.

Thomas: Right, the sporting mechanism that we see the most frequently is skiing, and after that it is most often motor vehicle wrecks, motorcycle wrecks, industrial accidents.

Dr. Miller: And is the repair of these intra-articular fractures difficult?

Thomas: It is and the operative piece that's most difficult is getting the cartilage lined up pretty much as close as you can anatomically and there are people that are specifically trained in exactly that.

Dr. Miller: Are you more successful now than you were 30 years ago in this treatment?

Thomas: We believe we are, due to some technological advances but also some advances in our understanding of the injury.

Dr. Miller: So is it true that the best outcome from one of these intra-articular fractures relates to getting it right at the time of surgery? I mean I guess you don't want to have to go back in and revise the surgery if you don't need to?

Thomas: Absolutely, like many things in medicine, your initial treatment is most critical and if the joint isn't aligned up correctly out of the gate, it's incredibly hard to recover from.

Dr. Miller: Are they most common in the knee, the hip, the ankles, wrists, shoulders?

Thomas: In the lower extremity, that is to say the leg. They are most common in the knee and the ankle. There are some articular injuries in the hip but that is certainly less common. In the arm, it is most common in the wrist.

Dr. Miller: From falling?

Thomas: Yes.

Dr. Miller: Okay how about shoulders?

Thomas: Shoulders will suffer some articular fractures but most of the fractures are just downstream from the joint itself.

Dr. Miller: What's the likelihood that that patient is going to get full function of that knee back? I know that's a hard question because it depends on the type of injury and the severity of the injury. But obviously things have changed for the better, as you mentioned before, so I gather that the ability of that person to come back and have a more functional life is increased.

Thomas: Right and it, as you said, varies with severity. I think the old school thinking on this if we go back a couple of decades was, "That's a very bad injury. You're never going to be the same again."

Our treatment now has focused more on, "This is maybe a bad injury or this is where you are on the spectrum on injury, and our goal is to get you as much of your function as possible," and that starts with us fixing the joints sooner, moving them sooner and mobilizing the patients in ways that we hadn't used previously.

Dr. Miller: We would see in the old movies that the person in the bed with a long leg cast on. We don't do that anymore. Do we?

Thomas: [inaudible 00:03:24] Three Stooges.

Dr. Miller: And that's kind of not where we see anymore, right. You're talking about, and I maybe think of that as the piece about mobility is you repair the fracture and then you get people back to a functional stage as rapidly as possible.

Thomas: Right and we say in orthopedics that we operate on the joint for two reasons, one is to mobilize the joint, and two is to mobilize the patient. So yes, they're not stuck in traction. We have to get them out of bed. It's good for your overall health and less muscle loss.

But secondly, we used to mobilize these joints in one position like the long leg cast for a long period of time. It was discovered couple of decades ago that motion is actually good for the cartilage.

Dr. Miller: Amazing.

Thomas: Right, and so our goal number one is to get the cartilage stable enough to meet goal number two which is move the joint.

Dr. Miller: You do the surgery, you say you get it right in the first time and it sounds to me like this is a team effort, team play. You probably pass them on to other physicians, physiatrists and so rehab would obviously play a big part in this, right?

Thomas: The orthopedic surgeon will sort of monitor and supervise much of the rehab. The physiatrist will coordinate in a multiply injured patient, the interplay between various specialists. And I think as surgeons post-operatively, our greatest role is in our interaction with the therapists and being very specific about what should be done.

Dr. Miller: So that's great team work at the university because you work very closely with the physical therapists on the in-patient unit, and then once they're out I guess you also have a relationship with the physical therapist in terms of how they're doing.

Thomas: Right that's kind of our last step and rounding on the orthopedic floor is they go into the room where the therapists are headquartered and just sort of touch base with them on each one of the patients that I've seen. And then post-op at the orthopedic center, we are blessed with a large crew of incredibly motivated physical therapists.

Dr. Miller: Nowadays, what is the length of time it takes from the time the surgery occurs to when that patient is pretty much done with physical therapy?

Thomas: It really depends on the injury. Most of the early motion work we have folks do for themselves and with joint fractures, at about six weeks. Then we turn them over to a physical therapist because I think "the bang for the buck" therapy-wise is after six weeks because then we can start strengthening it. After that we work on weight bearing and walking.

Dr. Miller: Now obviously if you're in a bad motor vehicle accident or some other kind of industrial accident, you're going to be transported to usually a trauma-1 facility where they would run into you or your colleagues would help repair an intra-articular fracture. But for some people, those that are injured on the ski slope, they might not immediately need to come to the hospital. They do have a fracture and it does need to be repaired. How would they find the best surgeon for this kind of a surgery or treatment?

Thomas: I think today most people, for things that are elective or semi-elective, like some of these injuries, most people turn to the internet and I think the qualifications you're looking for are someone who has the background in specific training for orthopedic trauma. You are looking for someone who fixes these injuries frequently. It's like anything else in life. If you are paying attention and you do it repeatedly, you can't help but get better at it.

And then you look for someone who is working with a team of the other people that are going to help to make you better. The nurses, the physical therapist, the after care.

Dr. Miller: Would it be a good recommendation for a patient to look first for a facility that has a trauma-1 designation, and then look inside to see who the surgeons are?

Thomas: That is the trauma-1 centers are generally where the people that are most qualified to treat these injuries, based on both training and volume of practice. That is where these folks congregate.

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