SRQ Magazine | February 2017
At our core, everything begins and ends with our bones. Without them, there would be no movement, no structure—essentially no body at all. Our bones contain markers that define our entire existence, from the marrow within that holds the potential to revitalize the body, to the tiniest joints in our fingers and toes, allowing us to put pencil to paper or heel to dance floor. Here, two expert orthopedic surgeons weigh in on the issues facing our complex internal framework.
SRQ: Especially in an area known for an aging population, what are the most common injuries you see? Dr. John T. Moor (Advanced SportsMedicine Center): My practice is mostly knees and shoulders and hips. I do arthroscopy and joint replacement—joint replacement for arthritis, ligament reconstructions, meniscus repairs, partial knees, cartilage transfers, stuff like that. Anything that athletes can beat up or older people can wear out. Dr. David A. Sugar (Sugar Orthopaedics): And I’m primarily focused on shoulders, knees and kids. Specifically to Sarasota, because of our very active older population, I see a lot of overuse injuries. There was an orthopedic surgeon who came up with a term around 15 years ago called Boomeritis—Baby Boomers kind of ushered in the era in the 1970s of working out, not just manual labor but actually working out. I see a lot of what I would call overuse injuries: people wearing themselves out, not listening to their bodies and not knowing when to stop. Then there is also arthritis, which is a kind of wearing out. And I treat people for tendonitis and a lot of rotator cuff stuff, which are the tendons in the shoulder. And for kids, I see a lot of fractures, but a lot of what I treat is pigeon toed, bowlegged, knock-kneed, scoliosis—I see a lot of scoliosis, which is curvature of the spine. In my practice today, I would say a third of the patients are kids, and about half of those are fractures…monkey bars and trampolines are bad.
What are the different approaches that you take for patients who are on the younger end of the spectrum versus the older? Moor: When you are a kid you heal differently than when you are an adult. Once you are an adult, you pretty much heal the same no matter whether you are 20 or 80. But, 80-year-olds are more prone to be injured because their bones are weaker, their ligaments and tissues are weaker. An 80-year-old’s wrist fracture heals about as quickly as a 20-year-old’s fracture heals, but 10-year-olds will heal that thing up in a couple of weeks, and an 80-year-old will be the typical adult: about six weeks. Growing bones are different than adult non-growing bones, but once you are an adult you’re not growing any more healing capacities. Similarly, all our tissues degenerate with time, everything in our whole body but our teeth degenerate over time. And so rotator cuffs go away, cartilage goes away, skin strength goes away. It all just degenerates over time. Sugar: I agree, but younger people, the 20s and 30s, are still able to push themselves as hard as they want and can bounce back. With older people, it’s more about learning and teaching them how to adapt what they do to preserve what they’ve got for as long as they can keep it.
What are some things that people can do to prevent having to have surgery, or to prevent having pain? Sugar: Weight’s a big one—a huge one. Staying fit, staying active and a healthy program once you get older, lower impact stuff, and then proper diet and getting enough sleep. It’s kind of standard stuff. I think a lot of what we see is weight related: as people get heavier, they degenerate faster. You get 40-year-olds who have a knee joint of an 80-year-old and they’re morbidly obese it is definitely from that. Moor: People come to the US for better medical care from all over the world because we have the best, but our populous is not necessarily the most healthy. How does that make any sense? Even though we have available health care and it’s world-class, we don’t take care of ourselves. We are one of the most obese populations in the world. Our nutrition is lousy. There is such a thing as malnutrition in the obese. In our country, when you have impoverished people, the problem is not they’re all skinny and wasting away—the most impoverished people here are the most obese people. We shoot ourselves in the foot. We know that marathon runners don’t destroy their knees—you can run 26.2 miles frequently and not destroy your body, but if you are 400 pounds, you will destroy your knees or hips or feet almost certainly. Because every step of every day, you pound your joints and your body never has a chance to catch up. Just like if you try to run a marathon every day you’d destroy your body—you have to take a break, so your body has a chance to catch up and it heals and you move on. Just like if you were to lift weights: your muscles get sore and you let them have a chance to heal up so they can get bigger and better. But if you do too much all the time, you over-use, and your muscles fail, which is when problems happen. The ways that we can have our population get older but more resilient to getting ill are: nutrition, ideal body weight and exercise. People all the time come in to my office and they’re taking 20 supplements but also smoking and drinking and they’re overweight and they don’t exercise. Almost all of our patients are on medicines—it’s a medicine world. If you are obese, you typically will have high blood pressure, diabetes, gastroesophageal reflux disease (GERD), sleep apnea, wound healing problems—the list goes on. And the treatment is to give them insulin and blood pressure medicine. That’s all treating the effect—the cure is to cut calories and go down to ideal body weight, and that cures diabetes. It doesn’t treat it, it cures it. And it cures heart disease, hyper-cholesterol, it cures blood pressure which causes strokes.
How do you balance a patient’s need to be on, for example, a proton pump inhibitor (PPI) medication (which can lead to weak bones and osteoporosis) for GERD or reflux and the long-term effects on the bones? How do you decide which ailment is more important? Sugar: I’ve been on PPI for 15 years, and if I don’t take it I’m miserable. I tried the diet stuff—even if you could do everything just perfect, you may still have reflux. I tell people they have to weigh the pros and the cons. Moor: Right, the PPIs can cause osteoporosis. So every time somebody comes in with 20 supplements, I say every medicine that does something has a side effect—which 100 percent of them do, there is no exception to the rule. If it has an effect, it has a side effect. Sugar: It’s a matter of having to decide, well do I want to feel good every day, or do I want to in 40 years wake up and have a broken hip? But there are also long-term effects to having reflux, like throat cancer. It comes down to quality of life decisions.
What are some of the new technologies that are entering into your operating rooms? Especially for the more specialized aspects of what you do. Sugar: The biggest one that has been getting a lot of press lately is PRP—platelet rich plasma and stem cell treatments. I’m starting to do some. I’ve kind of taken it with a grain of salt and stood back and watched. You take someone’s blood, spin it in a centrifuge and it separates into layers, and there is a layer with the platelets, and the platelets in general have a lot of healing potential—they release chemicals that attract healing cells and growth hormone. And with the stem cells, what I do is take the bone marrow and do the same thing: spin it and get all the stem cells, which also have a layer of platelets and they have a lot of factors that can heal tissue. I’m starting to use it little by little, because in medicine, the gold standard is evidence-based medicine with double blind prospective randomized studies. And there is not a single one in stem cell stuff. The PRP I find works great; stem cells I haven’t seen as much progress for arthritis—I’ve only been doing it for about a year so I don’t know if I’m necessarily convinced yet how much it does for regrowth of tissue.
What do the PRP and stem cell injections treat exactly? Sugar: Soft tissue, rotator cuff tears and repairs. I think for surgical things, it has the most potential. So you repair a rotator cuff, put the stem cells in the area and it helps the area heal quicker. I had my anterior cruciate ligament, my ACL, reconstructed two months ago; I took my stem cells from bone marrow and injected them into the new ligament to help it heal quicker. Most of the patients who come to my office interested in it are coming in for knee arthritis. I’m not so sure yet that it’s going to actually grow a layer of cartilage. I tell people that I don’t know how much is it going to make you feel better and for how long it is going to last. But people are getting it and little by little I’m seeing long enough follow-up that I can say, yes, you’re going to feel better. Now if it is it worth the cost—because it’s not covered by insurance, and thousands of dollars—is another matter.
So without concrete studies, you are kind of winging it. Sugar: Yes, a bit. We do have anecdotal studies; so we can see that Dr. so-and-so had 12 patients who had a rotator cuff repair and were treated with stem cells, and this is how they’ve done in 18 months. There are those kind of publications out there. Moor: The fact that there is not a randomized controlled trial is incriminating, because if we invent the best thing in the world, it behooves us to then say: here’s a placebo and here’s the real thing and do it on 100 patients here and 100 patients here, blinded to us, blinded to you, blinded to the patients and then test it to prove what it’s doing. A friend of mine, Jason Dragoo, an orthopedic surgeon at Stanford, does PRP and stem cell research—he says, for arthritic pain, if you inject this in the knee, it does not regrow cartilage. It does not regrow cartilage or cure arthritis. Although, there are unscrupulous people who are charging $6,000 or $8,000 to inject and tell people they are going to cure their arthritis and regrow their cartilage—there is no evidence of that. There is evidence to the contrary. It does help some people’s symptoms on the same basis as hyaluronic acid, which is lubricating fluid that your body naturally creates for every single joint—analogous to putting oil in your car’s engine. Moving parts have to have lubrication or they will wear themselves out, and your body creates hyaluronic acid lubricating fluid. When you get an arthritic joint, it becomes watery, like putting water in a car rather than oil—it’s not slippery enough to do a good job. So you put this hyaluronic acid back in and it makes it more slippery, and purportedly that makes you better. Some studies show that it’s placebo. Other studies show that it is a little bit better than placebo. But it’s certainly not a panacea. When it comes to PRP, there are a few studies that say that it does as well as hyaluronic acid. If hyaluronic acid is a placebo then that’s not so good; if it does some good, then it’s okay, but it’s still doesn’t grow cartilage. When you inject it into a tendon or a ligament, that’s where it’s biggest advantage is, because it is like fertilizer for collagen. Collagen is the stuff that holds our bodies together—without it we’d just fall apart. So Achilles tendonitis, patella tendonitis, tennis elbow, golfer’s elbow, biceps tendonitis—anywhere where the tendon has collagen that is failing—if you put in this fertilizer, it tends to want to regrow the cells. Has that been done in a double blind controlled study? No. So it’s a little bit sketchy right now. In the future, will we be there? Absolutely! Sugar: Another area that is blossoming and making big advances isn’t even technically what we’re doing surgically—pain management. Multi-modal it’s called, a multi-faceted approach to pain management. Preoperatively, particularly with big surgeries like knee replacements, we’re giving patients three or four different medications preemptively to deal with pain when they get out of surgery. It’s made big differences, especially with shortening hospital stays for joint replacements. Moor: It’s a lot of reeducation. The economics of healthcare today dictate that we have to get our patients through the process faster and more cheaply, and so part of that process is to get their pain under control so they are not sitting in the hospital on some narcotic drip gorked out after surgery. That scenario is over and done with. And it’s really good that it has been pushed like that. The number one speciality that prescribes the most narcotics of anybody in our country is not pain management, not surgeons, but family practice doctors. They by far and away prescribe the most narcotics of anybody because granny comes in for pain and they give her a bunch of narcotics. Narcotics don’t take your pain away. They make you not care so much. We have to kind of convince people to participate in therapies.
About Our Participants
Dr. John T. Moor, MD is the only dual-fellowship-trained (in arthroscopy and shoulder surgery) orthopedic surgeon in Sarasota, and he trained at the world-renowned Steadman-Hawkins Clinic in Denver (patients included the Denver Broncos, Colorado Rockies and US Ski Team) and the University of Iowa’s Hawkeye Sports Medicine Center. Dr. Moor has earned national recognition as one of America’s Top Surgeons by the Consumers’ Research Council of America. He has also been a guest speaker at national orthopedic conferences and has taught international orthopedic surgeons with the Arthroscopy Association of North America. He is an elected member of the American Orthopedic Society for Sports Medicine, an editor for the Journal of Shoulder and Elbow Surgery and an associate professor at Florida State University’s College of Medicine and Lake Erie College of Osteopathic Medicine.
Dr. David A. Sugar, MD earned his medical degree from the University of South Florida College of Medicine with honors in surgery. He completed his internship at the University of South Florida Department of Surgery and his residency in the Tampa Orthopaedic Program, Rush Presbyterian – St. Luke’s Medical Center and Shriner’s Hospital for Crippled Children in Chicago, IL. Dr. Sugar is board certified by the American Board of Orthopedic Surgery and is a member of the American Medical Association, the Florida Physicians Association and the American Academy of Orthopedic Surgeons. He has been published in journals such as the Journal of Biomechanics and has won several awards.